Ophthalmology and Optometry Coding Alert

Question: I have always been billing DME (durable medical equipment) using modifier EY only on items that the patient requests. However, I noticed that Medicare has been rejecting my claims recently. My submissions have been dismissed because they were "unprocessable." What does this mean?

Texas Subscriber

Answer: Keep in mind that whenever you bill for DME, you have to make two claims; one for the items Medicare is paying and another for those that the patient has requested but Medicare won't pay.

Do not put together ordered and non-ordered items on the same claim. Make a separate billing on ordered items. Claims containing a combination of ordered and nonordered items will be denied as unprocessable.

CMS instituted modifier EY (No physician or other licensed health care provider order for this item or service) to allow DME suppliers to submit claims to Medicare for items without a prescription. The EY modifier denotes that the supplier does not have a doctor's order for an item or service. The supplier must report its name and National Provider Identifier (NPI) as the ordering or referring physician on claims submitted without a physician order. The EY modifier must be on all line items for that claim.

You must append EY as well as a 'G' modifier to indicate the encounter's Advance Beneficiary Notice (ABN) status. If you have an ABN on file, use GA (Waiver of liability statement on file) on each of those items to indicate that you did get a signature for this claim. To indicate there is no ABN on file, append modifier GZ (Item or service expected to be denied as not reasonable and necessary). If there is no ABN on file, then the patient is not responsible for the charges.

Example: Claim for V2781 (Progressive lens, per lens). Report as V2781-RT-LT-EY-GA. You should append modifiers RT (Right side) and LT (Left side) to show that you provided both lenses.