Ophthalmology and Optometry Coding Alert

If your patient is likely to qualify for a free pair of glasses or contacts following cataract surgery, but they opt to get deluxe frames or progressive lenses instead, they will be responsible for the overage between the standard glasses and the deluxe version. In this case, you should ask the patient to sign an advance beneficiary notice (ABN) to let them know they’re responsible for the difference in cost between the frame types.

ABNs are also helpful in cases where a patient has already gotten free glasses or contacts following cataract surgery, but either wants a new pair or needs to replace them. In these cases, Medicare will not pay for the glasses, and the patient will be considered self-pay.

Never use “blanket” ABNs: You should not regularly require patients to sign ABNs “just in case” a payer denies a service. Instead, you must be sure that there is a reasonable basis for noncoverage associated with the issuance of each ABN, CMS says in its publication, “Advance Beneficiary Notice of Noncoverage.”

Covered services: For services that are normally a covered benefit but may not be covered due to lack of medical necessity or breach of frequency requirements, you must have a signed ABN if you want to collect payment from the beneficiary. You must issue the ABN when:

• You believe Medicare may not pay for an item or service
• Medicare usually covers the item or service
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this particular instance.

For instance: If a patient schedules a glaucoma test earlier than the 12-month frequency limit with no signs or symptoms indicating the need for further testing, you should tell the patient the reason you don’t expect Medicare to cover the service, and get the patient to sign an ABN. You should also append modifier GA (Waiver of liability statement issued as required by payer policy, individual case) to the procedure code, such as G0117 (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist) so that Medicare will automatically assign liability to the beneficiary upon denying the claim.

Generally not covered: You aren’t required to have a signed ABN on hand for services that are never covered by Medicare, such as refraction. However, some experts recommend getting an ABN even when you know Medicare statutorily doesn’t cover a particular service, because it engenders patient good will. Getting the signed ABN means you’re notifying the patient upfront that they will be responsible for a charge and how much they’ll expect to pay, ensuring that everyone is on the same page financially.

Be sure you use language in the ABN that the patient can easily understand — use verbal descriptions, not CPT® and ICD-10-CM codes, to describe the procedure and the patient’s medical condition. Include an estimate of the cost of the services. The patient must select an option and sign the ABN. In the case where the patient refuses to choose an option, you must annotate the form to that effect. Medicare payers may deem invalid forms that are incorrectly or incompletely filled out.

Where to keep it: You are required to provide the patient with a copy of the signed ABN, and you should keep the original ABN on file.