11

Part 6Part 6

Filing 3Filing 3rdrd Party Claims Party Claims

Addressing:Addressing:

• Medicare DME Supplier Codes and Medicare DME Supplier Codes and ModifiersModifiers

• Post-op Glasses (one pair per cataract Post-op Glasses (one pair per cataract surgery)surgery)

• Post-op Contact LensesPost-op Contact Lenses

22

DisclaimersDisclaimers

This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free.

It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

33

DisclaimerDisclaimer

• The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services.• The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

44

What is Medicare DMEWhat is Medicare DME

DME: DME: Durable Medical EquipmentDurable Medical Equipment supplied to supplied to Medicare RecipientsMedicare Recipients– WheelchairsWheelchairs– OxygenOxygen– Refractive Lenses to replace the missing crystalline lens Refractive Lenses to replace the missing crystalline lens

of the eyeof the eye Post Cataract surgeryPost Cataract surgery Congenital absenceCongenital absence

– Many, many other itemsMany, many other items

55

Who Manages Medicare Who Manages Medicare DMEDME

DME DME SuppliersSuppliers managed by the National Supplier managed by the National Supplier Clearinghouse (NSC), currently administered by Clearinghouse (NSC), currently administered by PalmettoGBA.PalmettoGBA.

DME DME ClaimsClaims handled by our DME carrier, Noridian handled by our DME carrier, Noridian Administrative Services.Administrative Services.

66

To Enroll as a Medicare SupplierTo Enroll as a Medicare Supplier

http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/National%20Supplier%20Clearinghouse

77

https://www.noridianmedicare.com/dme/coverage/lcd.htm

Our Medicare Supplier Administrative Contractor…

88

https://www.noridianmedicare.com/dme/coverage/lcd.htm

Local Coverage Determination Policy Article HCPCS Codes Covered

99https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses.htm

Local Coverage Determination

1010https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses.htm

Policy Article

1111

Cost to Become a Medicare Cost to Become a Medicare SupplierSupplier

To enroll as a supplier: ~$500 every three yearsTo enroll as a supplier: ~$500 every three years Cost of Surety Bond (if needed…)Cost of Surety Bond (if needed…)

1212

DME RequirementsDME Requirements

Accreditation (not needed by ODs)Accreditation (not needed by ODs)

Requires none-degree holding suppliers to obtain Requires none-degree holding suppliers to obtain accreditation from official accrediting body (initial cost accreditation from official accrediting body (initial cost $2500; + ~$1000 per year)$2500; + ~$1000 per year)

Surety BondsSurety Bonds

Requires some suppliers to obtain a $50,000 surety bond Requires some suppliers to obtain a $50,000 surety bond (costs $500-$1500 per year)(costs $500-$1500 per year)

1313

When Surety Bond is NeededWhen Surety Bond is Needed

A DMEPOS surety bond is needed by an ODs if A DMEPOS surety bond is needed by an ODs if s/hes/he

• Sells any DME other than post-op glasses or Sells any DME other than post-op glasses or CLsCLs

• Has an optician that is registered with DMEHas an optician that is registered with DME

• Filled out their 855S enrollment incorrectly Filled out their 855S enrollment incorrectly

• Dispensary has a different tax ID numberDispensary has a different tax ID number

• Fills outside Medicare post-op RXs w/o Fills outside Medicare post-op RXs w/o established relationship with patient…established relationship with patient…(more)(more)

http://www.palmettogba.com/Palmetto/Providers.nsf/files/suretybondfaqs09102009.pdf/$FIle/suretybondfaqs09102009.pdf

1414

Outside Rx and Need for Surety Bond

Written order for your patient by doctor in your Written order for your patient by doctor in your officeoffice– You have an established relationship –surety bond not You have an established relationship –surety bond not

required by Medicarerequired by Medicare

Written order by another doctorWritten order by another doctor (surgeon, walk in, (surgeon, walk in, etc.) You must either…etc.) You must either…– Purchase surety bond or…Purchase surety bond or…

– AOA: Establish a relationship with the patient (check AOA: Establish a relationship with the patient (check refraction, acuity, write Rx, document, etc.)refraction, acuity, write Rx, document, etc.)

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The supplier must have on file The supplier must have on file

A A written orderwritten order (complete description). (complete description). – Must be signed and dated by the treating physician; Must be signed and dated by the treating physician;

A properly executed A properly executed beneficiary authorizationbeneficiary authorization for for assigned claims; assigned claims;

A proper A proper advance beneficiary noticeadvance beneficiary notice (ABN) (ABN) if a if a coveredcovered item is item is personal preferencepersonal preference (not (not ordered by the physician)ordered by the physician)

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Valid written order that contains:Valid written order that contains:

Beneficiary's name Beneficiary's name Detailed description of the item(s) to be dispensed Detailed description of the item(s) to be dispensed Treating physician's signature Treating physician's signature Date the treating physician signed the orderDate the treating physician signed the order

1717

Order Form:

Quentin Quack OD 1/1/05

1818

Authorization FormAuthorization Form

As found on the CMS-1500, orAs found on the CMS-1500, or In-office equivalent, that remains in In-office equivalent, that remains in

effect until canceled by patienteffect until canceled by patient

1919http://www.cms.hhs.gov/BNI/02_ABN.asp

2020

Before submitting a claim to DME, Before submitting a claim to DME, the supplier must have on filethe supplier must have on file

Proof of delivery;Proof of delivery;

DME (DMEPOS) DME (DMEPOS) Supplier StandardsSupplier Standards should be should be given to patient & duplicate documented in given to patient & duplicate documented in record.record.

2121

(Proof of Delivery)

Received by _________________ Date __________

Patient Signature

Order Form:

Quentin Quack OD 1/1/05

2222

Medicare DME Supplier StandardsMedicare DME Supplier Standards Applicable Durable Medical Equipment Applicable Durable Medical Equipment

Supplier Standards must be followed by Supplier Standards must be followed by the supplier, and a copy given to the the supplier, and a copy given to the patient. patient.

•Read them

•Follow them

•Give a copy to the patient

https://www.noridianmedicare.com/dme/news/manual/chapter2.html%3f

2323

Regarding Medical Records…Regarding Medical Records…

It is expected that the patient’s medical records will reflect It is expected that the patient’s medical records will reflect the need for the care provided. the need for the care provided.

These records are not routinely submitted but must be These records are not routinely submitted but must be available upon request. available upon request.

Therefore, while it is not a requirement, it is a Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the appropriate medical records and maintain a copy in the beneficiary’s file. beneficiary’s file.

2424

Medical records must support the need for Medical records must support the need for refractive lenses as defined by Medicare*refractive lenses as defined by Medicare*

Pseudophakia (ICD-9 V43.1); or Pseudophakia (ICD-9 V43.1); or Aphakia (ICD-9 379.31); or Aphakia (ICD-9 379.31); or Congenital Aphakia (ICD-9 743.35). Congenital Aphakia (ICD-9 743.35).

*Medicare only covers refractive lenses to restore to restore vision normally provided by the natural lens of the vision normally provided by the natural lens of the eye. (quasi-prosthesis)eye. (quasi-prosthesis)

2525

One pair of glasses (lenses and frame) after each One pair of glasses (lenses and frame) after each cataract surgery. cataract surgery.

Lenses Lenses single vision ($36-$70 single vision ($36-$70 per lensper lens)* )* standard bifocal ($39-$81standard bifocal ($39-$81 per lensper lens)*)*standard trifocal. ($60-$108standard trifocal. ($60-$108 per lensper lens)*)*

Standard Frames ($61)*Standard Frames ($61)*

What is Covered?What is Covered?

*fees are approximate, current in 2012

2626

Basic Rules of DME CodingBasic Rules of DME Coding

Filing a DME claim with Noridian…the basics found Filing a DME claim with Noridian…the basics found at: at: https://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.htmlhttps://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.html

Specific Rules for Refractive Lens coding on Specific Rules for Refractive Lens coding on following slides…following slides…

2727

BOTTOM CMS-1500 Referring Dr. Data

Referring Doctor“JOHN SMITH”

Referring Doctor’sNPI

2828

BOTTOM CMS-1500 Qualifying Information

Example: Date assumed + date relinquished post-op care

+ # Post-op care days.

Date of Surgery and RT or LT

2929

Billing RemindersBilling Reminders

One of the following ICD-9 codes that justifies the One of the following ICD-9 codes that justifies the need must be included on the claim : need must be included on the claim : – V43.1 (pseudophakia); V43.1 (pseudophakia); (second diagnosis – first (second diagnosis – first

diagnosis is the cataract as per surgeon)diagnosis is the cataract as per surgeon) – 379.31(aphakia); 379.31(aphakia); (second diagnosis – first diagnosis is (second diagnosis – first diagnosis is

the cataract as per surgeon)the cataract as per surgeon) – 743.35 (congenital aphakia).743.35 (congenital aphakia).

3030

BOTTOM CMS-1500 Claim lines

V43.1

Date of Delivery

12

Primary diagnosis (used by surgeon)

2

3131

BOTTOM CMS-1500 Charges/Fee Data

2

V-codes with modifiers

Usual and customary fees charged (based on “per lens”)

3232

Non-Covered ItemsNon-Covered Items

Progressive Lenses V2781Progressive Lenses V2781

When billing claims for progressive lens, use the When billing claims for progressive lens, use the appropriate code for the standard bifocal (V2200-V2299) or appropriate code for the standard bifocal (V2200-V2299) or trifocal (V2300-V2399) lens trifocal (V2300-V2399) lens

Add a second line item using code V2781 for the difference Add a second line item using code V2781 for the difference between the charge for the progressive lens and the between the charge for the progressive lens and the standard lensstandard lens

3333

BOTTOM CMS-1500 Service & Materials Supplied

PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&C

V2203RTLT 9400 2

V2781GY 20600 2

3434

Non-Covered ItemsNon-Covered Items

Deluxe Frames V2025Deluxe Frames V2025

When billing claims for deluxe frames, use code V2020 for When billing claims for deluxe frames, use code V2020 for the cost of standard frames the cost of standard frames

Add a second line item using code V2025 for the difference Add a second line item using code V2025 for the difference between the charges for the deluxe frames and the between the charges for the deluxe frames and the standard framesstandard frames

3535

BOTTOM CMS-1500 Service & Materials Supplied

DELUXE FRAME V2025 IS DIFFERENCE FROM U&C

V2020 5200

V2025GY 9800

3636

Billing RemindersBilling Reminders

Use the RT and LT modifiers with all HCPCS codes in the refractive lenses policy with the following exceptions: – V2020

– V2025

When lenses are provided bilaterally and the same code is used for both lenses, bill both on the same claim line using LTRT and two units of service and total charge for both lenses.

3737

BOTTOM CMS-1500 Service & Materials Supplied

RTLT FOR BOTH EYES – UNITS OF TWO

V2750EYGARTLT 2

V2744EYGARTLT 2

V2780EYGARTLT 2

V2784EYGARTLT 2

3838

BOTTOM CMS-1500 Service & Materials Supplied

RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF

ONE V2750EYGART 1

V2750EYGALT 1

3939

Claims for Special ItemsClaims for Special Items

The following special items areThe following special items are covered only if covered only if documented as ordered by the physiciandocumented as ordered by the physician (OD or MD) (OD or MD)

– Anti-reflective coatingAnti-reflective coating (V2750), (V2750),

– TintsTints (V2744, V2745) or (V2744, V2745) or

– Oversize lensesOversize lenses (V2780) (V2780)

– PolycarbonatePolycarbonate or Trivex (V2784) for the patient with functionally or Trivex (V2784) for the patient with functionally monocular visionmonocular vision

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Billing Billing Reminders Reminders

Add Add KX modifierKX modifier for each of these items for each of these items specifically specifically ordered by the physicianordered by the physician: :

Add Add EY modifierEY modifier for each of these items provided as a for each of these items provided as a patient preferencepatient preference::

Add Add GA modifierGA modifier on personal preference items after on personal preference items after having patient sight ABNhaving patient sight ABN

Anti-reflective coatingAnti-reflective coating (V2750) (V2750) TintsTints (V2744, V2745) (V2744, V2745) Oversized lensesOversized lenses (V2780) (V2780) Polycarbonate or TrivexPolycarbonate or Trivex TM TM (V2784) for the patient with (V2784) for the patient with monocular visionmonocular vision

4141

BOTTOM CMS-1500 Service & Materials Supplied

•V2750KX

•V2744KX

•V2780KX

•V2784KX

KX MODIFIER WHEN ORDERED BY DOCTOR

4242

BOTTOM CMS-1500 Service & Materials Supplied

•V2750EYGA

•V2744EYGA

•V2780EYGA

•V2784EYGA

EY MODIFIER WHEN PATIENT PREFERENCE

GA MODIFIER WHEN ABN SIGNED BY PATIENT

4343

Non-Covered ItemsNon-Covered Items

UV coating (V2755) billed with polycarbonate lenses (V2784)

Tinted lenses used as sunglasses

– (V2745) tints

– (V2744) photochromatic lenses

4444

Non-Covered ItemsNon-Covered Items

Polycarbonate (V2784) or high index glass or plastic (V2782, V2783) for indications such as light weight or thinness

Scratch resistant coating (V2760),

Mirror coating (V2761),

Polarization (V2762),

Deluxe lens feature (V2702) (e.g., edge tx., etc.)

4545

Non-Covered ItemsNon-Covered Items Specialty occupational multifocal lenses (V2786) Specialty occupational multifocal lenses (V2786)

Hydrophillic soft contact lenses (V2520-V2523) used as a Hydrophillic soft contact lenses (V2520-V2523) used as a corneal dressing corneal dressing

Eyeglass cases (V2756)Eyeglass cases (V2756)

Low vision aids (V2600-V2615) Low vision aids (V2600-V2615)

Vision supplies, accessories, and/or service components of Vision supplies, accessories, and/or service components of another HCPCS vision code (V2797) another HCPCS vision code (V2797)

Contact lens cleaning solution and normal saline Contact lens cleaning solution and normal saline

4646

Modifier GYModifier GY

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/

• Used to indicate that the item or service is statutorily non-Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit).covered (not a Medicare Benefit).

• Patient is responsible for paymentPatient is responsible for payment

4747

BOTTOM CMS-1500 Service & Materials Supplied

•V2025GY

•V2760GY

•V2781GY

GY MODIFIER WHEN NONE COVERED ITEM

4848

KX, EY, and GA ModifiersKX, EY, and GA Modifiers

http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf

4949

KX, EY, and GA ModifiersKX, EY, and GA Modifiers

http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf

5050

Bifocal lenses in frames; or Bifocal lenses in frames; or Lenses in frames for far vision and lenses in frames Lenses in frames for far vision and lenses in frames

for near vision; or for near vision; or Contact lenses for far vision and lenses in frames Contact lenses for far vision and lenses in frames

for near vision worn simultaneously; or for near vision worn simultaneously; or Contact lenses and lenses in frames worn when the Contact lenses and lenses in frames worn when the

contacts have been removed.contacts have been removed.

For True aphakic patients, may For True aphakic patients, may supply one of the following…supply one of the following…

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Thank You for ListeningThank You for Listening

We hope this information has been We hope this information has been helpful.helpful.

Thank you for listening!Thank you for listening!

See our NOA Website for more 3See our NOA Website for more 3rdrd Party Educational Videos.Party Educational Videos.

33rdrd Party Services Party Services

Nebraska Optometric AssociationNebraska Optometric Association