Ophthalmology and Optometry Coding Alert

Question: I have a patient who wants to purchase a frame for $200. Medicare allows $74.06. How do I bill the remaining frame cost to the patient?

Michigan Subscriber

Answer: Medicare will cover glasses only for patients who have undergone cataract surgery. Also, Medicare will pay only for a pair of glasses fitted on standard frames. Should the patient chose to upgrade the frames, he would have to pay for the additional cost. In billing the patient, an advance beneficiary notice (ABN) is required informing him that he needs to pay the difference in the cost for the upgraded frames and the Medicare-approved standard frames.

The supplier, on the other hand, is required to submit claims to Medicare noting the purchase of upgraded frames as two separate items on the claim. The supplier will use V2020 (Frames, purchases) for the cost of the "standard frames" (the Medicareapproved amount) and V2025 (Deluxe frame) for the difference between the charges for the upgraded frames and the standard frames. Append modifier GA (Waiver of liability statement on file) to V2025 to show that you have a signed ABN from the patient. Tinted lenses used as sunglasses, scratch-resistant coating on lenses, and progressive lenses are not covered by Medicare.

Important: Before Medicare begins to pay its share, the patient must pay an annual $135 (in 2009) deductible for Part B services and supplies.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.