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DME Post-op Glasses Claims

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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 supplier PECOS and Accreditation How to file clean DME claims with Noridian What surgeon and surgery information must be included What three diagnoses are acceptable on a DME claim What narrative information is required on all Medicare post-op claims How to file each claim line What modifiers are required Additional resources available 

2 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

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.

4 Refractive Lens Coverage
In General, Medicare DME covers… Patient with implanted IOL after surgery One pair of glasses after each cataract surgery One set of contact lenses after each cataract surgery Patient without implanted IOL Aphakic glasses, replaced when medically necessary Aphakic contact lenses, replaced when necessary Combinations of the above

5 Refractive Lens Coverage
Noridian web site on coverage of refractive lenses has two resources regarding eligibility, restrictions, and coding regulations Local Coverage Determination (LCD) [13 pages] pdf Refractive Lens Policy Article [5 pages] pdf

6 Noridian LCD on Refractive Lenses pdf


8 Noridian Policy Article on Refractive Lenses
Policy Article Source: 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 address Complete detailed description of the item All options or additional features which will be billed separately Signature of physician (OD or MD) and date signed

12 Order Form: Quentin Quack OD /1/05



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 Signature Quentin 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 them Follow them Give copy to patient

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 complaints Pp 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); or Aphakia (ICD ); or Congenital Aphakia (ICD ).

20 Basic Rules of DME Coding
Filing a DME claim with Noridian…the basics found at: Specific 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 abbreviations Box 17b (NPI) The surgeon’s NPI Box 19 (narrative section) ? The date of the surgery ? Which eye was operated upon

22 BOTTOM CMS-1500 Referring Dr. Data
Referring Doctor’s NPI Referring Doctor “John Smith MD”

23 Date of Surgery: MMDDYYYY Eye operated: RT or LT
BOTTOM CMS Qualifying Information Example: 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 pseudophakia Also: aphakia, cong. aphakia Box 24, Line 1, Column A (date of service) Date glasses were delivered Box 24, Line 1, Column B (location of service) 12 [indicates location of use is at home]

25 BOTTOM CMS-1500 Claim lines
V43.1 12 Date of Delivery

26 DME Claims for Cataract Post-op Glasses
Box 24, Line 1, Column D (CPT code) V Codes for materials Example: 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 J Supplier’s NPI

27 From Noridian LCD

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

29 RT and LT Modifier Use RT and LT modifier on all HCPCS codes except frame codes. Lenses Tints Everything except frame Lenses provided bilaterally should use the RTLT modifier & units of 2.

30 V-Codes and Modifiers V-codes are the same as used for Medicaid and other 3rd parties Some DME Modifiers are the same as other 3rd Parties Some DME Modifiers are unique to DME

31 BOTTOM CMS-1500 Service & Materials Supplied

32 BOTTOM CMS-1500 Service & Materials Supplied

33 DME Written Orders and Unique Modifiers
DOCTOR’S ORDER Regarding the following lens features… V2750 anti-reflective coating V2744, V2745 tints (transitions &none-sunglass) V2780 oversized lenses V2784 polycarbonate lenses (monocular vision) DME wants to know.. Was the extra NEEDED, and ORDERED Or, was is a PATIENT PREFERENCE item

34 DME Written Orders and Unique Modifiers
DOCTOR’S ORDER If feature is specifically ordered by a physician (OD or MD) V2750 anti-reflective coating V2744, V2745 tints (transitions &none-sunglass) V2780 oversized lenses V2784 polycarbonate lenses (monocular vision) Written order should clearly indicate Dr. ordered it; claim should indicate by using the KX modifier Documentation for the need should be available on request.

35 BOTTOM CMS-1500 Service & Materials Supplied

36 DME Written Orders and Unique Modifiers
DOCTOR’S ORDER If one of the following lens feature is NOT ordered by a physician but is personal preference V2750 anti-reflective coating V2744, V2745 tints (transitions &none-sunglass) V2780 oversized lenses V2784 polycarbonate lenses (monocular vision) Claim should indicate it was personal preference by using the EY modifier ABN (advance beneficiary notice) should be obtained, GA modifier should also then be used.

37 BOTTOM CMS-1500 Service & Materials Supplied

38 None-Covered Items None-covered means NEVER covered
XXXXX None-covered means NEVER covered V2760 Scratch resistant coating V2781 Progressive lenses V2025 Deluxe frames A non-covered item is the patient’s responsibility. Use the GY modifier on non-covered items Assures that the patient’s Medicare Remittance Advice states patient is responsible for payment.

39 BOTTOM CMS-1500 Service & Materials Supplied

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. Difference for V2025 is $90.42.

42 BOTTOM CMS-1500 Service & Materials Supplied

43 Progressive Lenses V2200-V2299 first line of claim (Bifocal codes), or
V2300-V2399 first line of claim (Trifocal codes) V2781 next line of claim The 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) U&C for Progressive in your office $300 V2781 equals $206

45 BOTTOM CMS-1500 Service & Materials Supplied

46 UV Protection Covered on Glass lens
Covered on Plastic if less than 100% UV protection Document 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 supplied A copy of table with the lens type circled & UVA and UVB protection This protocol is not in LCD; Presented at a DME workshop in Omaha

48 BOTTOM CMS-1500 Service & Materials Supplied

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.

50 KX, EY, and GA Modifiers

51 KX, EY, and GA Modifiers Pg.9. August 2009

52 References Noridian is our DME MAC Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) NAS: Noridian Administrative Services, LLC

53 References NAS DME Supplier Manual Documentation required
Written order Proof of Delivery ABN Supplier Standards Claims Submission V-codes Pricing

54 References DME Happenings DME Carrier newsletter Changes in CMS policy
Updates in coding requirements Updates on documentation needed FAQs Changes in contact information Changes in Billing Requirements



57 ELECTRONIC CLAIMS: Noridian CEDI Electronic Data Interchange Information Bulletins
If file with Noridian electronically, must go through CEDI CEDI Puts out a plethora of bulletins each month regarding the new common electronic data interchange CEDI Will remove providers from database if inactive for 13 months. PG.4. February September 2009

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 Bonds Requires some suppliers to obtain a $50,000 surety bond (costs $500-$1500 per year) PECOS Medicare Database Medicare’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/he Fills outside Medicare post-op RXs w/o exam Sells any DME other than post-op glasses or CLs Has an optician that is registered with DME Filled 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 to check whether they are in PECOS As 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.

64 That’s all, Folks!! Dr. Quack

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