coding & reimbursement
Optical Claims: Avoiding Problems
Billing correctly for post-cataract eyeglasses isn't easy. Here are the pitfalls -- and how to avoid them.

As you know, Medicare will normally cover one pair of eyeglasses following cataract surgery with implantation of an IOL. However, there are several exceptions to this rule -- and filing a claim correctly can be tricky.

Q: When are eyeglasses not covered? Because Medicare's medical necessity requirement applies, when a patient undergoes more than one cataract operation the law doesn't guarantee payment for a pair of glasses following each surgery.

• If the two surgeries are widely separated in time, two pairs of glasses would probably be medically necessary and, therefore, covered.
• If both surgeries are performed within a short period of time, and the patient doesn't get glasses following the first surgery, then only one pair of glasses (following the second surgery) will be covered.
• If both surgeries are performed within a short period of time, and the patient gets glasses following the first surgery, a new frame may not be necessary. In this case, only the new lens for the second eye will be reimbursable (unless the second surgery causes the prescription in the first eye to change. In that case, both lenses would be covered).

If the frame is unusable following the second surgery, Medicare may reimburse for the lenses and a new frame.

Q: What are common errors when filling out the CMS-1500 claim form? The most common error is providing the wrong date of service. The service has not been completed until the glasses are delivered. (Remember: Medicare doesn't pay for services before they are performed.) Use the dispensing date as your date of service.

Other items to watch out for:

• Only put your name and UPIN in Box 17 and 17a if you're the doctor finalizing the prescription. (This isn't always the surgeon.)
• The date(s) of surgery and the operative eye must be noted in Box 19. (The carrier doesn't usually require the surgeon's name.)
• The place of service must be the patient's home. (Usually this will be 12 on the claim.)
• Remember that Medicare requires you to get a signed proof of delivery from the patient. You need an itemized statement of some sort with the patient's signature and date to prove that you delivered the glasses as your claim states. (A copy of the lab order may suffice if it includes all the necessary information.)
• When providing Medicare-covered eyeglasses you're required to give the patient a copy of Medicare's Supplier Standards. If you don't have a current copy, you can download it from the DMERC web site.

Q: What about coding? Coding is complex because there are multiple codes for various powers of single-vision lenses, bifocals, and trifocals. In fact, there are 14 possible codes for each type of lens! The most common error here is coding both lenses the same when one lens contains cylinder and the other doesn't. Be sure to code each lens separately.

Also, watch your modifiers:

• Use -RT and/or -LT for all lens codes.
• Use modifier -GA whenever you've had the patient sign an ABN because you believe the add-on (e.g., tints) won't be covered.
• The new modifier -EY indicates that an add-on wasn't ordered by the doctor for medical reasons -- i.e., the patient chose to purchase the add-on for personal reasons. Modifier -EY will cause the claim line to be denied.
• Bill these modifiers in this order (as applicable): -EY,-GA,-RT,-LT.

If you avoid these common errors, your Medicare claims for post-cataract eyeglasses will process more smoothly, and you'll avoid having to refund money in the event of a post-payment audit.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.