Presentation on theme: "DME Post-op Glasses Claims"— Presentation transcript:
1 DME Post-op Glasses Claims What is Medicare DME? Do I want to be a provider?How to sign up to be a DME supplierPECOS and AccreditationHow to file clean DME claims with NoridianWhat surgeon and surgery information must be includedWhat three diagnoses are acceptable on a DME claimWhat narrative information is required on all Medicare post-op claimsHow to file each claim lineWhat modifiers are requiredAdditional resources available
2 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
3 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.https://www.noridianmedicare.com/dme/index.html
4 Refractive Lens Coverage In General, Medicare DME covers…Patient with implanted IOL after surgeryOne pair of glasses after each cataract surgeryOne set of contact lenses after each cataract surgeryPatient without implanted IOLAphakic glasses, replaced when medically necessaryAphakic contact lenses, replaced when necessaryCombinations of the above
5 Refractive Lens Coverage Noridian web site on coverage of refractive lenses has two resources regarding eligibility, restrictions, and coding regulationsLocal Coverage Determination (LCD) [13 pages]https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_ pdfRefractive Lens Policy Article [5 pages]https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_ pdf
6 Noridian LCD on Refractive Lenses https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_ pdf
8 Noridian Policy Article on Refractive Lenses Policy Article Source: https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_ pdf
9 DME Refractive Lens Coding What you must have on file before you can file a claim with Noridian………….
10 Before submitting a claim to DME, 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)
11 DME Written Orders DME states a written order must contain: Beneficiary’s name and full addressComplete detailed description of the itemAll options or additional features which will be billed separatelySignature of physician (OD or MD)and date signed
15 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.
16 Order Form: Quentin Quack OD 1/1/05 Received by _________________ Date __________(Proof of Delivery)Patient SignatureQuentin Quack OD /1/05
17 Medicare DME Supplier Standards The Durable Medical Equipment Supplier Standards must be followed closely by the supplier, and a copy of the standards must be given to the patient.Read themFollow themGive copy to patienthttps://www.noridianmedicare.com/dme/enroll/25_standards.html
18 Medicare DME Supplier Standards Standards 6: Be sure to document any warranty coverage.Standard 9: Make sure your phone listing matches your information on your NSC enrollment.Standard 12: You must document delivery of Rx, and also explanation of proper care of Rx.Standard 16: A copy of the standards must be given to patient, and you must document that you have done so.Standard 19: Make sure to have a written complaint protocol on hand.Standard 20: Keep a copy of complaintsPp April 2009
19 Before submitting a claim to DME, the supplier must have on file Medical records supporting that the refractive lenses are necessary to restore vision normally provided by the natural lens of the eye because the patient has:Pseudophakia (ICD-9 V43.1); orAphakia (ICD ); orCongenital Aphakia (ICD ).
20 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…
21 DME Claims for Cataract Post-op Glasses Box 17 (Name of Referring Physician)The surgeon’s name, no abbreviationsBox 17b (NPI)The surgeon’s NPIBox 19 (narrative section)? The date of the surgery? Which eye was operated upon
22 BOTTOM CMS-1500 Referring Dr. Data Referring Doctor’sNPIReferring Doctor“John Smith MD”
23 Date of Surgery: MMDDYYYY Eye operated: RT or LT BOTTOM CMS Qualifying InformationExample: Date assumed + date relinquished post-op care+ # Post-op care days.Date of Surgery: MMDDYYYY Eye operated: RT or LT
24 DME Claims for Cataract Post-op Glasses Box 21 line 1 (diagnosis)Usual diagnosis: V43.1 pseudophakiaAlso: aphakia, cong. aphakiaBox 24, Line 1, Column A (date of service)Date glasses were deliveredBox 24, Line 1, Column B (location of service)12 [indicates location of use is at home]
25 BOTTOM CMS-1500 Claim lines V43.112Date of Delivery
26 DME Claims for Cataract Post-op Glasses Box 24, Line 1, Column D (CPT code)V Codes for materialsExample: V2020 [frame]Example: V2304RT [trifocal lens for right eye…no spaces or dashes]Box 24, Line 1, Column F (charges)Your total usual and customary charge for that item (including customary dispensing fee or markup)Box 24, Line 1, Column JSupplier’s NPI
28 BOTTOM CMS-1500 Charges/Fee Data V-codes with modifiersUsual and customary fees charged (based on “per lens”)
29 RT and LT ModifierUse RT and LT modifier on all HCPCS codes except frame codes.LensesTintsEverything except frameLenses provided bilaterally should use the RTLT modifier & units of 2.
30 V-Codes and ModifiersV-codes are the same as used for Medicaid and other 3rd partiesSome DME Modifiers are the same as other 3rd PartiesSome DME Modifiers are unique to DME
31 BOTTOM CMS-1500 Service & Materials Supplied RTLT FOR BOTH EYES – UNITS OF TWOV2750EYGARTLTV2744EYGARTLTV2780EYGARTLTV2784EYGARTLT
32 BOTTOM CMS-1500 Service & Materials Supplied RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF ONEV2750EYGARTV2750EYGALT
33 DME Written Orders and Unique Modifiers DOCTOR’S ORDERRegarding the following lens features…V2750 anti-reflective coatingV2744, V2745 tints (transitions &none-sunglass)V2780 oversized lensesV2784 polycarbonate lenses (monocular vision)DME wants to know..Was the extra NEEDED, and ORDEREDOr, was is a PATIENT PREFERENCE item
34 DME Written Orders and Unique Modifiers DOCTOR’S ORDERIf feature is specifically ordered by a physician (OD or MD)V2750 anti-reflective coatingV2744, V2745 tints (transitions &none-sunglass)V2780 oversized lensesV2784 polycarbonate lenses (monocular vision)Written order should clearly indicate Dr. ordered it; claim should indicate by using the KX modifierDocumentation for the need should be available on request.
35 BOTTOM CMS-1500 Service & Materials Supplied KX MODIFIER WHEN ORDERED BY DOCTORV2750KXV2744KXV2780KXV2784KX
36 DME Written Orders and Unique Modifiers DOCTOR’S ORDERIf one of the following lens feature is NOT ordered by a physician but is personal preferenceV2750 anti-reflective coatingV2744, V2745 tints (transitions &none-sunglass)V2780 oversized lensesV2784 polycarbonate lenses (monocular vision)Claim should indicate it was personal preference by using the EY modifierABN (advance beneficiary notice) should be obtained,GA modifier should also then be used.
37 BOTTOM CMS-1500 Service & Materials Supplied EY MODIFIER WHEN PATIENT PREFERENCEGA MODIFIER WHEN ABN SIGNED BY PATIENTV2750EYGAV2744EYGAV2780EYGAV2784EYGA
38 None-Covered Items None-covered means NEVER covered XXXXXNone-covered means NEVER coveredV2760 Scratch resistant coatingV2781 Progressive lensesV2025 Deluxe framesA non-covered item is the patient’s responsibility.Use the GY modifier on non-covered itemsAssures that the patient’s Medicare Remittance Advice states patient is responsible for payment.
39 BOTTOM CMS-1500 Service & Materials Supplied GY MODIFIER WHEN NONE COVERED ITEMV2025GYV2760GYV2781GY
40 Deluxe Frames & Lenses Frames. V2020 first line of claim. V2025 second line of claim.The dollar amount for V2025 should be the difference between U&C deluxe charge and standard frame charges.
41 Deluxe Frames & Lenses Frame Example. Deluxe Frame U&C $150. DME Allowed for basic frame $59.58.https://www.noridianmedicare.com/dme/fees/index.htmlDifference for V2025 is $90.42.
42 BOTTOM CMS-1500 Service & Materials Supplied DELUXE FRAME V2025 IS DIFFERENCE FROM U&CVV2025GY
43 Progressive Lenses V2200-V2299 first line of claim (Bifocal codes), or V2300-V2399 first line of claim (Trifocal codes)V2781 next line of claimThe dollar amount for V2781 should be the difference between the first line of claim and your U&C progressive charge
44 Progressive Lenses EXAMPLE: V2203 bifocal pays $47 per lens ($94) https://www.noridianmedicare.com/dme/fees/index.htmlU&C for Progressive in your office $300V2781 equals $206
45 BOTTOM CMS-1500 Service & Materials Supplied PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&CV2203RTLTV2781GY
46 UV Protection Covered on Glass lens Covered on Plastic if less than 100% UV protectionDocument type of plastic lens used,Document less 100% UV protection.Maintain a table of various plastic lenses w/ UVA & UVB protection.
47 UV Protection Every DME patient record should contain Their lab invoice listing the type of plastic lens suppliedA copy of table with the lens type circled & UVA and UVB protectionThis protocol is not in LCD; Presented at a DME workshop in Omaha
48 BOTTOM CMS-1500 Service & Materials Supplied KX WHEN UV COAT ORDERED BY DOCTORV2755KX
49 Filing two claims for the same DME patient prescription All items ordered by the physician are filed on one claim, with the referring physician’s name and NPI being listed in box 17 and 17b.All none-covered items and personal preference items are filed on a separate claim (at the same time), with the box 17 and 17b containing the DME supplier’s name and NPI.
57 ELECTRONIC CLAIMS: Noridian CEDI Electronic Data Interchange Information Bulletins If file with Noridian electronically, must go through CEDICEDI Puts out a plethora of bulletins each month regarding the new common electronic data interchangeCEDI Will remove providers from database if inactive for 13 months.PG.4. February September 2009https://www.noridianmedicare.com/dme/claims/edi.html
58 Recent DME Challenges Accreditation Surety Bonds Requires none-degree holding suppliers to obtain accreditation from official accrediting body (initial cost $2500; and ~$1000 per year)Surety BondsRequires some suppliers to obtain a $50,000 surety bond (costs $500-$1500 per year)PECOS Medicare DatabaseMedicare’s database of providers and suppliers. Must be kept up-to-date by you.
59 Accreditation and Surety Bonds The DMEPOS surety bond and accreditation requirements have been the subject of several CMS bulletins and health care provider trade publication articles.ODs do not need accreditation.ODs do need surety bonds in some circumstances
60 When Surety Bond is Needed A DMEPOS surety bond is needed by an ODs if s/heFills outside Medicare post-op RXs w/o examSells any DME other than post-op glasses or CLsHas an optician that is registered with DMEFilled out their 855S enrollment incorrectly (PECOS)Their dispensary has a different tax ID number
61 Medicare PECOS Database To Avoid Claim Denial, Make Sure that You, and All Providers that Refer to You, Are In the Medicare PECOS System
62 Online PECOS You must have updated your PECOS enrollment since 2003 If a referral or an order is involved in any claim, both PECOS enrollments (“referred by” Dr. and “referred to” Dr.) must be updated and correct.According to CMS, physicians can use https://pecos.cms.hhs.gov/pecos/login.do to check whether they are in PECOSAs of May, CMS claimed that online enrollment is “twice as fast” as paper PECOS enrollment. (not for original enrollment, however.)
63 PECOS Claim Requirements If a referring or ordering provider is included on a DME claim, (areas 17 & 17b), then:1. That provider and his/her NPI must be in the PECOS system;2. The provider’s name must be in all upper case;3. Use no abbreviations or nick-names;4. Do not proceed name with “Dr.”5. Look for the referrer in PECOS system (available soon) before providing service.6. Otherwise, claim will be denied.And you cannot bill the patient.