Presentation on theme: "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."— 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. http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7SFLC76127?opendocument 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 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] https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.pdf Refractive Lens Policy Article [5 pages] https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_10-1-09.pdf
6 Noridian LCD on Refractive Lenses https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.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
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 (Proof of Delivery) Received by _________________ Date __________ Patient Signature Order Form: Quentin Quack OD 1/1/05
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. https://www.noridianmedicare.com/dme/enroll/25_standards.html 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. 8-9.. April 2009 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-9 379.31); or Congenital Aphakia (ICD-9 743.35).
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.html https://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.html 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 “John Smith MD” Referring Doctor’s NPI
23 BOTTOM CMS-1500 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: 379.31 aphakia, 743.35 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 Date of Delivery 12
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
28 BOTTOM CMS-1500 Charges/Fee Data 1 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 3 rd parties Some DME Modifiers are the same as other 3 rd Parties Some DME Modifiers are unique to DME
31 BOTTOM CMS-1500 Service & Materials Supplied RTLT FOR BOTH EYES – UNITS OF TWO V2750EYGARTLT 2 V2744EYGARTLT 2 V2780EYGARTLT 2 V2784EYGARTLT 2
32 BOTTOM CMS-1500 Service & Materials Supplied RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF ONE V2750EYGART 1 V2750EYGALT 1
33 DME Written Orders and Unique Modifiers 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 DOCTOR’S ORDER
34 DME Written Orders and Unique Modifiers 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. DOCTOR’S ORDER
35 BOTTOM CMS-1500 Service & Materials Supplied V2750KX V2744KX V2780KX V2784KX KX MODIFIER WHEN ORDERED BY DOCTOR
36 DME Written Orders and Unique Modifiers 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. DOCTOR’S ORDER
37 BOTTOM CMS-1500 Service & Materials Supplied V2750EYGA V2744EYGA V2780EYGA V2784EYGA EY MODIFIER WHEN PATIENT PREFERENCE GA MODIFIER WHEN ABN SIGNED BY PATIENT
38 None-Covered Items 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. XXXXX
39 BOTTOM CMS-1500 Service & Materials Supplied V2025GY V2760GY V2781GY GY MODIFIER WHEN NONE COVERED ITEM
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.html Difference for V2025 is $90.42.
42 BOTTOM CMS-1500 Service & Materials Supplied DELUXE FRAME V2025 IS DIFFERENCE FROM U&C V2020 5200 V2025GY 9800
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) https://www.noridianmedicare.com/dme/fees/index.html U&C for Progressive in your office $300 V2781 equals $206
45 BOTTOM CMS-1500 Service & Materials Supplied PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&C V2203RTLT 9400 2 V2781GY 20600 2
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 V2755KX KX WHEN UV COAT ORDERED BY DOCTOR
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.
51 KX, EY, and GA Modifiers Pg.9. August 2009August 2009
52 References Noridian is our DME MAC Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) NAS: Noridian Administrative Services, LLC https://www.noridianmedicare.com/dme/index.html
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 2009 September 2009February 2009 September 2009 https://www.noridianmedicare.com/dme/claims/edi.html
58 Recent DME Challenges Accreditation 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-$1500 per year) PECOS Medicare Database Medicare’s database of providers and suppliers. Must be kept up-to-date by you.
59 Accreditation and Surety Bonds The DMEPOS surety bond and accreditation requirements have been the subject of several CMS bulletins and health care provider trade publication articles. ODs do not need accreditation. ODs do need surety bonds in some circumstances
60 When Surety Bond is Needed A DMEPOS surety bond is needed by an ODs if s/he Fills outside Medicare post-op RXs w/o exam Sells any DME other than post-op glasses or CLs Has an optician that is registered with DME Filled out their 855S enrollment incorrectly (PECOS) Their dispensary has a different tax ID number http://www.palmettogba.com/Palmetto/Providers.nsf/files/suretybondfaqs09102009.pdf/$FIle/suretybondfaqs09102009.pdf
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 http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf
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 PECOS https://pecos.cms.hhs.gov/pecos/login.do As of May, CMS claimed that online enrollment is “twice as fast” as paper PECOS enrollment. (not for original enrollment, however.) http://www.wpsmedicare.com/j5macpartb/publications/communique/current/_files/1009comm.pdf
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. http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf