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Supplier numbers needed
Medicare claims for post-cataract glasses are more involved and error prone than other claims. Make sure you have supplier numbers.
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One year ago, a busy cataract practice added an optical dispensary to create a full-service environment. Patients enjoyed the opportunity to purchase their eyeglasses on site upon receipt of their prescriptions. The physician partners believed they were offering a good service and looked forward to a profitable venture. Unfortunately, the year-end financial review revealed that all Medicare claims for post-cataract eyeglasses were denied and written off as uncollectible by the billing office.
Why did Medicare deny all their claims for reimbursement?
Billing Medicare for post-cataract surgery glasses can be more difficult than one would anticipate. The billing office filed these claims to their Medicare Part B carrier with the practice’s group provider identification number. This is incorrect because Durable Medical Equipment Regional Carriers (DMERCs) adjudicate claims for post-cataract eyeglasses. Four such carriers have jurisdiction over the entire country. In order to bill Medicare DMERC for post-cataract eyeglasses, the practice must obtain a supplier number; this is in addition to the group or physician provider numbers. The application form for a supplier number is the CMS-855-S (S for supplier).
After submitting the application form, a supplier number may be issued. This usually takes about 6 to 8 weeks, assuming additional information is not required. A contractor representative visits the office prior to issuance of a number to verify the legitimacy of the business and that there is a sign identifying the optical dispensary by name and showing business hours that is visible to the public. The representative also verifies that the practice is aware of Medicare’s supplier standards and will adhere to them, that the operation has a complaint process, and that liability insurance exists. A letter follows from the NSC indicating both the supplier number and its effective date. A supplier number is required for each physical location (dispensary) and may be used to submit claims to any DMERC. Services may not be provided until the effective date of the supplier number.
The billing office professes that they adjusted the claims because they were unaware that the law provides that Medicare cover “one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens” in a beneficiary’s lifetime. Because the medical necessity requirement of Medicare regulations applies to pseudophakic patients, there is no guarantee these patients will always receive a pair of glasses (or contacts) following each surgery; it may not be medically necessary.
Further review of the dispensary’s handling of these claims revealed several other issues to address. Medicare does not cover all features of eyeglasses. Coverage depends on medical necessity of the items. Prescription lenses and a standard frame to hold them are medically necessary, but tints, photochromic lenses, over-size lenses, antireflective coatings and polycarbonate lenses are rarely required or covered. When the item is supplied for cosmetic reasons or for personal convenience, the Medicare beneficiary is responsible for full payment. The patient is notified of responsibility and agrees to pay by signing the Advance Beneficiary Notice (ABN) form when ordering these items. Collect the full retail charge for the items and append modifiers EY and GA to the HCPCS codes for these items on the claim.
Document thoroughly
Explicit documentation of medical necessity in the physician’s chart and prescription is necessary to claim reimbursement for additional features when they are determined by the physician to be necessary for a particular patient. For example, some features are necessary for certain patients: polycarbonate for one-eyed patients, tint for patients with retinitis pigmentosa, or oversize lenses for extra large patients whose facial features cannot be accommodated with average size frames.
In the unusual instance when the physician identifies one of these rarely covered items as medically necessary, append the KX modifier (formerly ZX) to the HCPCS code on the claim. The chart documentation supports the medical necessity with a credible reason given as justification.
Claim completion is tedious, and some requirements do not mirror claim completion for clinic services. For example, the place of service is usually 12 (home); it is never 11 (office). The date on the claim must be the date the items were delivered to the patient. Generally, that is the dispensing date, not the order date. The HCPCS V-codes are used to describe eyeglasses, contact lenses and other vision supplies. Numerous codes exist and while a pair of eyeglasses may include two single vision, bifocal or trifocal lenses, coding for the lenses might not be the same for both lenses. Each type of lens has a number of different codes, depending upon the prescription. Code each lens discretely.
Additional forms and documentation requirements exist for these claims. Proof that the patient received the eyeglasses must be maintained in the supplier’s files for 7 years and made available to the DMERC upon request. An acceptable receipt must include the following:
- Patient’s name
- Quantity and detailed description of the item(s) being dispensed
- Brand name, serial number or other identification of the item(s)
- Patient’s signature and date
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The form and format are not specified. Usually, the optician’s order form includes specific references to manufacturer, model, brand names and other unique descriptors. The wholesale lab order may also contain itemization of the eyeglasses’ components. Opticians retain these documents as a record of the job. It is a simple matter to obtain the patient’s signature at the time of delivery on the optician’s record as a delivery receipt.
In order to obtain Medicare payment for covered post-cataract eyeglasses and contact lenses, the optical dispensary must have a physician’s prescription, also called a physician’s order. This prescription must be signed and dated by the prescribing physician (original ink signature and date required) and must be maintained in the supplier’s files. For optical dispensaries that are an integral part of an ophthalmologist’s or optometrist’s practice, the patient’s medical record will contain most of the required information.
CMS imposes many rules on suppliers that seem strange to the average medical practice. The re quirements for prescriptions and proof of delivery are examples. Another example is CMS’s Supplier Standards rules. These are 21 standards that must be followed by the supplier (dispensary). A copy of the standards must be provided to each Medicare beneficiary when he or she receives covered items. A copy should be posted in the dispensary.
The standards are statements that the supplier will follow all applicable laws and regulations, and treat the beneficiary fairly. Most are pertinent to an optical dispensary, with the exception of numbers 5 and 14. The full text is available in the October 11, 2000, Federal Register or on the DMERC Web sites.
Because of all of these issues, past Medicare claims for post-cataract eyeglasses were not recoverable. Once a supplier number is secured and the dispensary adheres to these documentation and billing requirements, they will be able to proceed with billing for post-cataract eyeglasses.