Ophthalmology and Optometry Coding Alert

Waivers are the key to getting paid when a patient chooses expensive frames and lenses (which Medicare doesnt completely cover) after cataract surgery.

Medicare will pay for lenses and framesup to a point. For example, what if the patient selects deluxe frames? What if the patient wants new glasses after a second cataract surgery done three months after the first? Does the coverage vary depending on whether the patient is aphakic or pseudophakic? We talked to a reimbursement consultant and an office manager for some answers.

A Medicare patient is entitled to one standard pair of glasses after each cataract surgery with an IOL implant (pseudophakia). The refraction is not covered, even though the glasses are covered. The law provides a maximum benefit to Medicare beneficiaries of no more than one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.

Medicare publishes a fee schedule that includes payment rates for frames, lenses, and a variety of additional options such as tints and coatings. If the patient chooses a more expensive or deluxe frame, or a progressive, no-line multi-focal lens or lenses, the patient must sign a waiver allowing the practice to bill him or her directly for the difference in cost, explains Mary Pat Johnson, COMT, senior consultant with Corcoran Consulting Group, a San Bernardino, CA-based company specializing in reimbursement and compliance for ophthalmology. Most ophthalmology practices dont know they can use a waiver to get paid, says Johnson. The waiver allows the practice to bill the patient up-front for the extra costs; you dont need to wait for the EOB to be returned. The patient must be offered standard frames and lenses and should be informed that they will be paying for the additional costs that exceed what Medicare will pay. If the patient selects deluxe frames and/or lenses after being advised, then the patient must sign the waiver and it should be kept on file. Medicare can demand to see the waiver if the patient complains he or she was never informed of the right to make a choice.

Bobbi Bachman, billing and insurance supervisor for Wyomissing Optometric Center in Wyomissing, PA, says, With DMERC (Durable Medical Equipment Regional Carrier), we can collect right up front, if we have that waiver. The waiver should be a typed, affirmative statement signed by the patient, such as:

I have been advised that Medicare covers only standard frames and lenses. I have been given a choice of selecting a standard frame and/or lenses or deluxe frames and/or lenses. I have chosen deluxe frames and/or lenses, and I understand that I will pay for the additional cost of the deluxe [...]