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 frames and lenses beyond what Medicare will cover. I agree to pay these additional costs.

There are two basic reasons why the glasses might cost more than the Medicare allowable: The patient wants fancy frames; or the patient wants fancy lenses, such as Varilux, special tints or progressive lenses.

The code for standard frames is V2020; for deluxe frames, it is V2025. For progressive lenses, you should use V2781. We split it right on the claim form, explains Bachman. In other words, there is one entry (V2020) for the standard frames, with the Medicare Fee Schedule rate next to that. Then there is a second entry (V2025) for the deluxe portion of the frames with that fee listed as the difference between your price for the deluxe frames and the Medicare Fee Schedule for standard frames.

Pseudophakia Versus Aphakia

The Medicare regulations say a patient can have up to two pairs of glasses if they are pseudophakic (V43.1). But that doesnt mean that after the second cataract surgery, a patient always gets an entirely new set of frames and lenses, says Johnson. If the second surgery happens relatively soon, the patient doesnt need everything replaced, the consultant notes. The frame and both lenses were likely replaced after the initial surgery. Based on medical necessity, this patient would probably only need one lens replaced after the second surgery.

Bachman agrees, saying a patient gets a new frame after the first cataract surgery with IOL implant, and then, for the second surgery, only the lens would be replaced.

Patients who are aphakic (379.31, no IOL implant) have a different Medicare coverage policy. The aphakic patient is entitled to glasses and/or contacts that replace both the distance- and near-vision functions as often as is medically necessary. Medicare covers any of the following: a pair of contacts for distance vision and two pairs of glasses, one for distance and one for near vision; no contacts and a pair of bifocals; or a pair of distance glasses and a pair of near glasses if the patient cannot tolerate contacts and/or bifocals. If there is medical necessity such as glasses being broken or scratched too badly to see through, a significant change in the refraction or if the contact lens is lost or damaged, the patient can receive additional glasses and/or contact lens replacements. The medical necessity must be well documented in the medical record and described when filing these claims, but Medicare does cover them.