Presentation on theme: "Part 6 Filing 3rd Party Claims"— Presentation transcript:
1 Part 6 Filing 3rd Party Claims Addressing:Medicare DME Supplier Codes and ModifiersPost-op Glasses (one pair per cataract surgery)Post-op Contact Lenses
2 DisclaimersThis 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 DMEDME: Durable Medical Equipment supplied to Medicare RecipientsWheelchairsOxygenRefractive Lenses to replace the missing crystalline lens of the eyePost Cataract surgeryCongenital absenceMany, 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.
11 Cost to Become a Medicare Supplier To enroll as a supplier: ~$500 every three yearsCost 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 BondsRequires 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/heSells any DME other than post-op glasses or CLsHas an optician that is registered with DMEFilled out their 855S enrollment incorrectlyDispensary has a different tax ID numberFills 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 officeYou have an established relationship –surety bond not required by MedicareWritten 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 nameDetailed description of the item(s) to be dispensedTreating physician's signatureDate the treating physician signed the order
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 SignatureQuentin 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 themFollow themGive a copy to the patienthttps://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); orAphakia (ICD ); orCongenital 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.Lensessingle 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.htmlSpecific Rules for Refractive Lens coding on following slides…
27 BOTTOM CMS-1500 Referring Dr. Data Referring Doctor’sNPIReferring Doctor“JOHN SMITH”
28 Date of Surgery and RT or LT BOTTOM CMS Qualifying InformationExample: Date assumed + date relinquished post-op care+ # Post-op care days.Date of Surgery and RT or LT
29 Billing RemindersOne 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 linesPrimary diagnosis (used by surgeon)V43.1212Date of Delivery
31 BOTTOM CMS-1500 Charges/Fee Data 2V-codes with modifiersUsual 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) lensAdd 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&CV2203RTLTV2781GY
34 Non-Covered Items Deluxe Frames V2025 When billing claims for deluxe frames, use code V2020 for the cost of standard framesAdd 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&CVV2025GY
36 Billing RemindersUse the RT and LT modifiers with all HCPCS codes in the refractive lenses policy with the following exceptions:V2020V2025When 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 TWOV2750EYGARTLTV2744EYGARTLTV2780EYGARTLTV2784EYGARTLT
38 BOTTOM CMS-1500 Service & Materials Supplied RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF ONEV2750EYGARTV2750EYGALT
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) orOversize 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 visionBilling RemindersAdd 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 DOCTORV2750KXV2744KXV2780KXV2784KX
42 BOTTOM CMS-1500 Service & Materials Supplied EY MODIFIER WHEN PATIENT PREFERENCEGA MODIFIER WHEN ABN SIGNED BY PATIENTV2750EYGAV2744EYGAV2780EYGAV2784EYGA
43 Non-Covered ItemsUV coating (V2755) billed with polycarbonate lenses (V2784)Tinted lenses used as sunglasses(V2745) tints(V2744) photochromatic lenses
44 Non-Covered ItemsPolycarbonate (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinnessScratch 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 dressingEyeglass 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 ITEMV2025GYV2760GYV2781GY
50 For True aphakic patients, may supply one of the following… Bifocal lenses in frames; orLenses in frames for far vision and lenses in frames for near vision; orContact lenses for far vision and lenses in frames for near vision worn simultaneously; orContact 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 ServicesNebraska Optometric Association