How to bill for post-op visual aids
Edited by Walt Whitley, O.D., Jason Miller, O.D., and Charles Brownlow, O.D., AOAExcelTM Medical Records Consultants
Billing and coding for post-operative visual aids can be challenging and frustrating. Here are some tips and resources to help ease the process, plus answers to commonly asked questions about Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).
Medicare does not pay for glasses, contact lenses or low-vision devices except for diagnoses related to cataracts (one pair per lifetime per eye after cataract surgery with implant) or surgical or congenital aphakia (frequency based on a doctor's recommendation). If the diagnosis is not related to cataract extraction with implant or aphakia, there is no point in billing the supply of glasses, contacts or low vision devices to Medicare.
When billing Medicare for post-op spectacles, possible payable diagnosis codes include:
- V43.1 (pseudophakia): one frame and two lenses per operated eye.
- 379.31 (aphakia): one frame and two lenses per year or on a reasonable and necessary basis.
- 743.35 (congenital aphakia): one frame and two lenses per year or on a reasonable and necessary basis.
When billing for standard lenses:
- For one or two lenses, bill the correct HCPCS code (V21xx, V22xx, or V23xx) on separate lines for each eye; use modifier RT or LT and the fee for one lens at your usual and customary (U&C) fee.
When billing for progressive lenses:
- First: Bill for standard lenses (see above).
- Then: When billing for only one lens, bill V2781 with a quantity of one and a RT or LT modifier.
- Finally: When billing for two lenses, bill V2781 with a quantity of two without a modifier.
Local coverage determination guidelines can be very helpful. They include details for specific upgrades and billing procedures. For example, in Ohio a section of the refractive lens policy (Billing and Coding Guidelines) states:
"When billing claims for progressive lens, use the appropriate code for the standard bifocal (V2200-V2299) or trifocal (V2300-V2399) lens and a second line item using code V2781 for the difference between the charge for the progressive lens and the standard lens."
Polycarbonates (V2784) are covered only for patients with functional vision in only one eye. If this were a patient preference item, you would also add the EY modifier (no physician order), and this item would be on a separate claim form. All items with no physician order should be billed on a separate claim form.
Answers to common questions
Q: I have heard about Medicare charging ODs to provide after-cataract glasses (around $523). Could you please explain this to me?
Unfortunately, this is accurate. DME Centers for Medicare & Medicaid Services (CMS) re-credentialing: All suppliers of DMEPOS, including eyeglasses and contact lenses for post-operative cataract patients, are subject to the fee. If you enrolled in Medicare (participating or non-participating), you may write prescriptions for your patients, but you are not registered as a supplier of DMEPOS. The patient will not receive a benefit unless the supplier is DMEPOS-credentialed. If you are neither a supplier nor enrolled with Medicare, the patients will not be reimbursed for their glasses or contact lenses based on your prescription or those supplied by you.
Remember, the fee covers the provider for three years, so it's not as bad as it sounds. In addition, optometrists are exempt from the surety bond requirement as long as they do not fill prescriptions from outside the practice. If a new patient appears with a prescription from a different doctor, we recommend making the patient your own patient by creating a record form, gathering demographic information, performing visual acuities and possibly an automated refraction.
The National Supplier Clearing House offers a chart showing accreditation and surety bond exemptions for supplier types.
Q: When filing for upgrades on post-operative glasses not ordered by a physician, should I use EY or GA modifier to the Healthcare Common Procedure Coding System? For example: V2750 RTLTEY or RTLTGA?
For items not ordered by the physician that are a patient preference (no order), submit V2750 RT/LT EY GA. Items with the EY modifier should be on a separate claim form. The EY indicates there is no physician order, and GA indicates you have the patient's signature on an Advance Beneficiary Notice (ABN), making payment the patient's responsibility. Make sure to look at your local coverage determination's (LCD) website. It's an excellent resource!
These are just two of the common questions we receive at firstname.lastname@example.org. If you have other questions, contact the Codeheads.