Ophthalmology and Optometry Coding Alert

Question: Are patients undergoing keratoconus workup or contact lens fitting still required to sign an advance beneficiary notice (ABN)? Why is it necessary when Medicare won't pay for it anyway?

Answer: According to CMS, "ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e., care that is never covered) or fails to meet a technical benefit requirement (i.e. lacks required certification)." You are correct that contact lens fitting (92310, Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia) is never a covered service by Medicare.

Therefore, you are not required to obtain the ABN, but you may want to consider voluntarily doing this as a means of notifying the patient of non-coverage and financial responsibility.

You are also not required to submit the non-covered service to Medicare unless the patient requests this to be done for the purpose of obtaining a denial for a secondary insurance or does not believe the service in non-covered.

You need to append modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to the non-covered code when you submit the claim.

When is it mandatory to provide an ABN to a Medicarebeneficiary? CMS requires a provider to notify a beneficiary in advance when he or she believes that items or services will likely be denied either as not reasonable and necessary or as constituting custodial care.