Ophthalmology and Optometry Coding Alert

There are a few HCPCS codes that your DME MAC will never cover. Make sure that the Medicare beneficiary knows he is fully responsible for payment for "never covered" items, advises Maggie M. Mac, CMM, CPC, CPC-E/M, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.

You may voluntarily provide the patient with an advance beneficiary notice (ABN) for "never covered" services; even though it's not a Medicare requirement, an ABN is a great way to provide the patient with information regarding his financial responsibility. You may have him sign and date the ABN, then provide the patient with a copy and keep the original on file. Append modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to these HCPCS codes.

Although individual rules may vary, do not expect coverage from your DME MAC for the following:

• V2025 ��" Deluxe frame

• V2702 ��" Deluxe lens feature

• V2756 ��" Eyeglass case

• V2760 ��" Scratch-resistant coating, per lens

• V2761 ��" Mirror coating, any type, solid, gradient or equal, any lens material, per lens

• V2762 ��" Polarization, any lens material, per lens

• V2781 ��" Progressive lens, per lens

• V2782 ��" Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens

• V2783 ��" Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens.

Tip: You don't need to append modifier EY (No physician or other licensed healthcare provider order for this item or service) to these HCPCS codes. If an item is never approved, like V2025, then GY is the only modifier you should append.

"In fact, you should not file a claim for 'never covered' services unless asked to do so by the patient or if the patient needs a denial in order to submit to a secondary insurance that may provide coverage," says Mac. "Always remember to append modifier GY to the 'never covered' services to let Medicare know you are aware the services are never covered, however, a denial is needed for the patient."

Note: Beginning March 3, 2008, and prior to March 1, 2009, Medicare contractors will accept either the current ABN-G and ABN-L or the revised ABN as valid notification. But starting on March 1, 2009, Medicare contractors will accept only a properly executed revised ABN (CMS R-131) as valid notification.

For more information, see "Eliminate NEMB Jumble With New ABN" in Ophthalmology Coding Alert, Vol. 11, No. 6.