Dispensing Developments
An update on new codes, being prepared for unannounced site inspections, and rules for required documentation.
BY SUZANNE L. CORCORAN, C.O.E.

As you know, Medicare will cover one pair of eyeglasses following cataract surgery with implantation of an IOL, as medically necessary. This year, however, a number of important coding and reimbursement changes were made that affect the dispensing of these glasses. Here, I'd like to review those changes, along with some other key issues that have escaped many practices' notice.

2004 Coding Changes

The most important new HCPCS coding rules are described below, by topic.

Polycarbonate lenses. Polycarb or Trivex lenses are usually ordered because patients like their light weight and thinner appearance, or because the patient's lifestyle calls for lenses that are less likely to break under high impact.

Previously: These lenses had no separate code.

Now: Polycarbonate lenses have their own code, V2784. Most of the time these lenses will be considered cosmetic, and therefore patient-pay. However, these lenses may be considered medically necessary when very specific medical necessity documentation is included in the medical record (e.g., the patient is blind in one eye). In that case, submit the claim with modifier -KX (specific medical necessity documentation is on file). The rest of the time, use modifier -EY on the claim to indicate that the lenses were not ordered by the physician as medically necessary.

High-index lenses. These lenses are usually prescribed because they're thin and light, which benefits patients with prescriptions that would otherwise produce heavy glasses.

Previously: V2730 was used to describe high-index lenses because of the material's special base curve.

Now: The following new codes should be used to describe high-index lenses:

► V2782 (index from 1.54 to 1.65 if the lens is plastic; from 1.60 to 1.79 if the lens is glass)

► V2783 (index equal to or greater than 1.66 if the lens is plastic, or 1.80 if the lens is glass).

Tints. This includes photochromic coatings.

Previously: Codes V2740, V2741, V2742, V2743 and V2744 were used to describe different types of tints.

Now: A new code, V2745, has been added to describe all tints except photochromic; this replaces codes V2740, V2741, V2742 and V2743, which have been deleted. You can continue to use V2744 for photochromic coatings. (Use modifier -EY on the claim to indicate that the tint was not ordered by the physician as medically necessary.)

UV coating. The DMERCs have now decided that plastic and polycarbonate lenses have inherent UV protection, and have changed policy accordingly.

Previously: UV coating for any lens was covered when ordered by the doctor. No special documentation was required.

Now: UV coating will no longer be separately covered for plastic lenses. However, UV coating on glass lenses will still be covered, when ordered by the physician. (Use code V2755.) This effectively makes UV coating a patient-pay item most of the time, since glass lenses are rarely dispensed.

Lenticular lenses. The codes for these lenses have been updated.

Previously: These lenses were coded using V2x16 and V2x17.

Now: The older codes have been replaced with V2121 (single vision), V2221 (bifocal), and V2321 (trifocal).

Other new codes. The following codes have been added, even though Medicare won't reimburse for these items, making the patient responsible for payment. (The codes may be useful for record-keeping within your office.)

► V2761 (mirror coating)

► V2762 (polarization)

► V2756 (eyeglass cases)

► V2786 (specialty occupational multifocal lenses)

► V2797 (vision supply, accessory and/or service component of another HCPCS vision code).

When using these codes, remember to add modifier -EY to indicate that the item or feature was not ordered by the physician and that you expect a denial. You will also need to have an Advance Beneficiary Notice (ABN) that itemizes the non-covered items, signed by the patient.

Unannounced Site Inspections

You may have heard about a huge Medicare scam involving power wheelchairs that took place in Texas last year. What does this have to do with you?

Unfortunately, your postcataract eyeglasses are funded by Medicare under the same law that pays for wheelchairs, hospital beds, and home oxygen. The power wheelchair fraud has prompted a crackdown on all types of Medicare suppliers -- including optical dispensaries.

One major result of this is an increase in unannounced site inspections. If you're the subject of such a visit, a representative of the DMERC will come to your office to verify that you're in compliance with Medicare rules and regulations.

Here are some of the key things the representative will be looking for:

Signage. Your name and business hours must be clearly displayed for patients and potential customers.

Supplier Standards. You must be able to demonstrate that you provide a copy of the Supplier Standards to each and every patient that receives Medicare-covered eyeglasses from your dispensary.

Receipts. Be prepared to show that you're getting a signed and dated proof of delivery for all Medicare eye-glasses dispensed.

Assignment of benefits. You must have a signed statement from your patients that you have their permission to file claims and receive payment for their Medicare benefit. The statement must use the specific language required by Medicare. (You should be getting patients to sign this for each pair of Medicare eyeglasses that you dispense.)

ABN. You must be able to demonstrate that you notify patients in advance using an ABN form when you dispense extra features that won't be covered by Medicare (tints, deluxe frames, etc.). This form must be completed, signed and dated by the patient prior to dispensing.

Clarifications

In January, CMS issued the following clarifications regarding delivery instructions and records retention for Medicare post-cataract eyeglass dispensing:

Keeping records. Records must be kept by your dispensary for at least 7 years.

Delivery receipt documentation. The following is required:

► You must have a delivery receipt (proof of delivery) signed and dated by the patient or the patient's designee. A notation by the dispensing personnel is not sufficient.

► The delivery receipt must include an itemization of the components of the glasses. Many practices use a copy of the lab order because that usually includes all of the features of the glasses and describes the frame.

Filling an outside prescription. If a prescription originates within your practice, much of the supporting documentation is contained in the medical chart. This is obviously not the case when you're filling a prescription written by an outside provider. In this situation, Medicare specifies that the following elements must be included on the prescription:

► the patient's name and full address

► the diagnosis (either narrative or ICD-9 code)

► a description of the item(s) -- narrative, or brand name and model number

► all options and additional items that are separately ordered (e.g., polycarbonate lens when required)

► the physician's original ink signature and date. Both the signature and date must be personally entered by the doctor; a stamped or surrogate signature is not acceptable.

If some of this information is missing, contact the practice that issued the prescription to complete your records.

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