Excerpted from page 44 of the March 2018 edition of AOA Focus.
AOA's coding experts frequently receive questions regarding the appropriate coding for postoperative glasses. Here's what you need to know:
Medicare will cover one pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an intraocular lens (IOL). Replacement frames, eyeglass lenses and contact lenses are noncovered.
Medicare will pay for one pair of post-cataract surgery glasses per lifetime per eye after cataract surgery. You also should review any local coverage determinations (LCDs) to find out if there are any local policy stipulations. Additionally, you also may want to call the Durable Medical Equipment Regional Carrier for your area to see if the patient is presently eligible for the glasses. Some LCDs clarify, "If a beneficiary has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, Medicare covers only one pair of eyeglasses or contact lenses after the second surgery. If a beneficiary has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye)."
Diagnoses to report
Payable diagnosis codes include:
- Z96.1 (pseudophakia)
- H27.01, H27.02, H27.03 (aphakia)
- Q12.3 (congenital aphakia)
CPT codes to report
For one or two lenses, bill the correct Healthcare Common Procedure Coding System code (V21xx, V22xx, or V23xx) on separate lines for each eye; use modifier RT or LT and the fee for one lens at your standard fee.
If you are billing for eyeglasses or contact lenses, you should submit claims to your Medicare Durable Medical Equipment Administrative Contractor (DME MAC). Find a list of DME MACs.
Fees for DME suppliers
All suppliers of Durable Medical Equipment, Orthotics and Prosthetics (DMEPOS), including eyeglasses and contact lenses for postoperative cataract patients, are subject to an enrollment and revalidation fee. The AOA continues to advocate with the Centers for Medicare & Medicaid Services so that doctors who are enrolled in Medicare as physicians should be exempt from this fee.
To stay abreast of code changes and the latest coding information, access the AOA's coding resources:
- Online resources. For up-to-date codes and resources, access AOA's coding information at aoa.org/coding and AOA Coding Today.
- Got a coding question? If you have specific coding questions that are not addressed through AOA Coding Today, direct them to AOA's Coding Experts by completing the online form.
- Reference manuals. Purchase the 2018 CPT code bundle at AOA Marketplace.
If you have suggestions on how the AOA can best support the coding needs of doctors of optometry, please contact Kara Webb, AOA's associate director for coding and regulatory policy, by email or call 703.837.1018.
Ask the coding experts
If you have any questions regarding Medical Records and Coding, please submit them by using the Coding Experts Submission Form and one of our coding experts will be in contact with you.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2023, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.