KX or EY may save your V2784 or V2755 claim. If you're providing refractive lenses for cataract surgery patients, you'll need to unravel your DME MAC's complex coding and billing rules to claim deserved Medicare reimbursement. The challenge: Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal, e.g., after cataract surgery, or who have congenital absence). Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens. Most DME Medicare Administrative Contractors (DME MACs) specify that your claim for refractive lenses must be linked to one of these ICD-9 codes to prove medical necessity: Append KX for Doctor-Ordered Extras The key to DME MAC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code. The standard benefit is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass. If the patient or the doctor want more features, a modifier will be necessary on the claim. The prescribing physician must specifically order the special lens; it cannot be the patient's preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity of the item you're claiming. Example: In these cases, report the lens with modifier KX (V2784-KX) and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, "best corrected VA OS 20/400" should suffice. Additionally, Medicare considers ultraviolet protection (V2755, U-V lens, per lens) reasonable and necessary after a cataract extraction. But you can only claim V2755 if the UV coating is applied to glass or plastic lenses. If UV protection is inherent in the lens material (as with polycarbonate lenses), you cannot report V2755 as an add-on code. Don't claim both: Along with V2755 and V2784, Medicare will sometimes pay for the following items if they are medically necessary: Use EY and GA for Patient Preferences What if the prescribing physician did not specifically order an item, but the patient wants it anyway? Append modifier EY (No physician or other licensed healthcare provider order for this item or service) to patient-preference items. Append modifier EY to V2744, V2745, V2750, and V2780 if the patient selects these items without a specific order from the prescribing physician, says DME MAC Noridian's local coverage decision (LCD) for refractive lenses. If the DME MAC will not cover an item, you are responsible for obtaining a signed Advance Beneficiary Notice of Noncoverage (ABN) from the patient, and appending modifier GA (Waiver of liability statement on file) to the services you submit to the Medicare carrier. Be sure to provide the patient with a copy of the completed ABN and retain the original on file. You may also need to append modifiers LT (Left side) and RT (Right side). If you're providing the same lens on both sides, bill both on the same line of the claim form, append both LT and RT, and claim two units of service. Example: Tip: Watch for POS Errors Hidden trap: The place of service (POS) code you include on the claim depends on the patient's place of residence. For DME, the POS is the place where the patient uses the equipment. You could report POS code 12 (Home), but never POS code 11 (Office). The date of service for the claim is the date the patient receives the DME. Online resource: