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Part 6 Filing 3rd Party Claims

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1 Part 6 Filing 3rd Party Claims
Addressing: Medicare DME Supplier Codes and Modifiers Post-op Glasses (one pair per cataract surgery) Post-op Contact Lenses

2 Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

3 Disclaimer • The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. • The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

4 What is Medicare DME DME: Durable Medical Equipment supplied to Medicare Recipients Wheelchairs Oxygen Refractive Lenses to replace the missing crystalline lens of the eye Post Cataract surgery Congenital absence Many, many other items

5 Who Manages Medicare DME
DME Suppliers managed by the National Supplier Clearinghouse (NSC), currently administered by PalmettoGBA. DME Claims handled by our DME carrier, Noridian Administrative Services.

6 To Enroll as a Medicare Supplier

7 Our Medicare Supplier Administrative Contractor…
https://www.noridianmedicare.com/dme/coverage/lcd.htm

8 Local Coverage Determination Policy Article HCPCS Codes Covered
https://www.noridianmedicare.com/dme/coverage/lcd.htm

9 Local Coverage Determination
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses.htm

10 Policy Article https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses.htm

11 Cost to Become a Medicare Supplier
To enroll as a supplier: ~$500 every three years Cost of Surety Bond (if needed…)

12 DME Requirements Accreditation (not needed by ODs) Surety Bonds
Requires none-degree holding suppliers to obtain accreditation from official accrediting body (initial cost $2500; + ~$1000 per year) Surety Bonds Requires some suppliers to obtain a $50,000 surety bond (costs $500-$1500 per year)

13 When Surety Bond is Needed
A DMEPOS surety bond is needed by an ODs if s/he Sells any DME other than post-op glasses or CLs Has an optician that is registered with DME Filled out their 855S enrollment incorrectly Dispensary has a different tax ID number Fills outside Medicare post-op RXs w/o established relationship with patient…(more)

14 Outside Rx and Need for Surety Bond
Written order for your patient by doctor in your office You have an established relationship –surety bond not required by Medicare Written order by another doctor (surgeon, walk in, etc.) You must either… Purchase surety bond or… AOA: Establish a relationship with the patient (check refraction, acuity, write Rx, document, etc.)

15 The supplier must have on file
A written order (complete description). Must be signed and dated by the treating physician; A properly executed beneficiary authorization for assigned claims; A proper advance beneficiary notice (ABN) if a covered item is personal preference (not ordered by the physician)

16 Valid written order that contains:
Beneficiary's name Detailed description of the item(s) to be dispensed Treating physician's signature Date the treating physician signed the order

17 Order Form: Quentin Quack OD /1/05

18 Authorization Form As found on the CMS-1500, or
In-office equivalent, that remains in effect until canceled by patient

19

20 Before submitting a claim to DME, the supplier must have on file
Proof of delivery; DME (DMEPOS) Supplier Standards should be given to patient & duplicate documented in record.

21 Order Form: Quentin Quack OD 1/1/05
Received by _________________ Date __________ (Proof of Delivery) Patient Signature Quentin Quack OD /1/05

22 Medicare DME Supplier Standards
Applicable Durable Medical Equipment Supplier Standards must be followed by the supplier, and a copy given to the patient. Read them Follow them Give a copy to the patient https://www.noridianmedicare.com/dme/news/manual/chapter2.html%3f

23 Regarding Medical Records…
It is expected that the patient’s medical records will reflect the need for the care provided. These records are not routinely submitted but must be available upon request. Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the beneficiary’s file.

24 Medical records must support the need for refractive lenses as defined by Medicare*
Pseudophakia (ICD-9 V43.1); or Aphakia (ICD ); or Congenital Aphakia (ICD ). *Medicare only covers refractive lenses to restore vision normally provided by the natural lens of the eye. (quasi-prosthesis)

25 What is Covered? One pair of glasses (lenses and frame) after each cataract surgery. Lenses single vision ($36-$70 per lens)* standard bifocal ($39-$81 per lens)* standard trifocal. ($60-$108 per lens)* Standard Frames ($61)* *fees are approximate, current in 2012

26 Basic Rules of DME Coding
Filing a DME claim with Noridian…the basics found at: https://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.html Specific Rules for Refractive Lens coding on following slides…

27 BOTTOM CMS-1500 Referring Dr. Data
Referring Doctor’s NPI Referring Doctor “JOHN SMITH”

28 Date of Surgery and RT or LT
BOTTOM CMS Qualifying Information Example: Date assumed + date relinquished post-op care + # Post-op care days. Date of Surgery and RT or LT

29 Billing Reminders One of the following ICD-9 codes that justifies the need must be included on the claim : V43.1 (pseudophakia); (second diagnosis – first diagnosis is the cataract as per surgeon) 379.31(aphakia); (second diagnosis – first diagnosis is the cataract as per surgeon) (congenital aphakia).

30 Primary diagnosis (used by surgeon)
BOTTOM CMS Claim lines Primary diagnosis (used by surgeon) V43.1 2 12 Date of Delivery

31 BOTTOM CMS-1500 Charges/Fee Data
2 V-codes with modifiers Usual and customary fees charged (based on “per lens”)

32 Non-Covered Items Progressive Lenses V2781
When billing claims for progressive lens, use the appropriate code for the standard bifocal (V2200-V2299) or trifocal (V2300-V2399) lens Add a second line item using code V2781 for the difference between the charge for the progressive lens and the standard lens

33 BOTTOM CMS-1500 Service & Materials Supplied
PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&C V2203RTLT V2781GY

34 Non-Covered Items Deluxe Frames V2025
When billing claims for deluxe frames, use code V2020 for the cost of standard frames Add a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames

35 BOTTOM CMS-1500 Service & Materials Supplied
DELUXE FRAME V2025 IS DIFFERENCE FROM U&C V V2025GY

36 Billing Reminders Use the RT and LT modifiers with all HCPCS codes in the refractive lenses policy with the following exceptions: V2020 V2025 When lenses are provided bilaterally and the same code is used for both lenses, bill both on the same claim line using LTRT and two units of service and total charge for both lenses.

37 BOTTOM CMS-1500 Service & Materials Supplied
RTLT FOR BOTH EYES – UNITS OF TWO V2750EYGARTLT V2744EYGARTLT V2780EYGARTLT V2784EYGARTLT

38 BOTTOM CMS-1500 Service & Materials Supplied
RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF ONE V2750EYGART V2750EYGALT

39 Claims for Special Items
The following special items are covered only if documented as ordered by the physician (OD or MD) Anti-reflective coating (V2750), Tints (V2744, V2745) or Oversize lenses (V2780) Polycarbonate or Trivex (V2784) for the patient with functionally monocular vision

40 Anti-reflective coating (V2750)
Tints (V2744, V2745) Oversized lenses (V2780) Polycarbonate or Trivex TM (V2784) for the patient with monocular vision Billing Reminders Add KX modifier for each of these items specifically ordered by the physician: Add EY modifier for each of these items provided as a patient preference: Add GA modifier on personal preference items after having patient sight ABN

41 BOTTOM CMS-1500 Service & Materials Supplied
KX MODIFIER WHEN ORDERED BY DOCTOR V2750KX V2744KX V2780KX V2784KX

42 BOTTOM CMS-1500 Service & Materials Supplied
EY MODIFIER WHEN PATIENT PREFERENCE GA MODIFIER WHEN ABN SIGNED BY PATIENT V2750EYGA V2744EYGA V2780EYGA V2784EYGA

43 Non-Covered Items UV coating (V2755) billed with polycarbonate lenses (V2784) Tinted lenses used as sunglasses (V2745) tints (V2744) photochromatic lenses

44 Non-Covered Items Polycarbonate (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness Scratch resistant coating (V2760), Mirror coating (V2761), Polarization (V2762), Deluxe lens feature (V2702) (e.g., edge tx., etc.)

45 Non-Covered Items Specialty occupational multifocal lenses (V2786)
Hydrophillic soft contact lenses (V2520-V2523) used as a corneal dressing Eyeglass cases (V2756) Low vision aids (V2600-V2615) Vision supplies, accessories, and/or service components of another HCPCS vision code (V2797) Contact lens cleaning solution and normal saline

46 Modifier GY http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit). Patient is responsible for payment

47 BOTTOM CMS-1500 Service & Materials Supplied
GY MODIFIER WHEN NONE COVERED ITEM V2025GY V2760GY V2781GY

48 KX, EY, and GA Modifiers

49 KX, EY, and GA Modifiers

50 For True aphakic patients, may supply one of the following…
Bifocal lenses in frames; or Lenses in frames for far vision and lenses in frames for near vision; or Contact lenses for far vision and lenses in frames for near vision worn simultaneously; or Contact lenses and lenses in frames worn when the contacts have been removed.

51 Thank You for Listening
We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3rd Party Educational Videos. 3rd Party Services Nebraska Optometric Association


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