Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.
From the May 2015 edition of AOA Focus, page 54.
If you write prescriptions for covered Part D drugs and you are not enrolled in Medicare or have a valid record of opting out, you will need to submit an enrollment application or an opt-out affidavit to your Medicare Administrative Contractor (MAC) by June 1, 2015, or earlier.
The Affordable Care Act, Section 6405, "Physicians who order items or services are required to be Medicare-enrolled physicians or eligible professionals," requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries. This would apply to the prescribing of medications as well as optical devices.
There are two ways to submit your enrollment application electronically using the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or by completing the paper CMS-855O application. Luckily, an application fee is not required as part of this application submission. The CMS-855O, which is a shorter, abbreviated form of the standard CMS-855I, should only be completed if you are seeking to enroll solely to order and refer and/or prescribe Part D drugs. While the CMS-855O form states it is for "physicians and nonphysician practitioners who want to order and refer," it is appropriate for use by prescribers who also want to enroll just to prescribe Part D drugs. If you wish to enroll to be reimbursed for all of the covered services furnished to Medicare beneficiaries, you must still complete the CMS-855I application.
A doctor of optometry who wants to opt out of Medicare must submit an opt-out affidavit to the MAC within his or her specific jurisdiction. Your opt-out information must be current and includes an affidavit to be completed every two years. A National Provider Identifier (NPI) is required to be submitted on the affidavit. Doctor of optometry who do not wish to enroll in the Medicare program may "opt out." This means that neither the physician nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out of pocket and neither party is reimbursed by Medicare.
In an effort to prepare the prescribers and Part D sponsors for the December 1, 2015, enforcement date, CMS made an enrollment file that identifies all registered physicians and eligible professionals who are enrolled in Medicare in an approved or opt-out status. This enrollment file is available on the CMS website. It contains some data but is considered a test file because the Part D prescriber enrollment requirement is not yet applicable. The file displays physician and eligible professional eligibility on or after November 1, 2014. That would include currently enrolled, new approvals, or changes from opt-out to enrolled status as of November 1, 2014. The file will include the provider's NPI, first and last names, effective and end dates, and if appropriate, opt-out flag.
Finally, the value of this new database is shown in confirming that other Doctor of optometry, surgeons or therapists whom you co-manage patients with are enrolled correctly. If they are not on the active, you run the risk of nonapproval for your services, your prescriptions and increased costs for your patients.
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.