Optometry Coding & Billing Alert

Modifiers KX and EY are the keys to reimbursement--but don't forget GA

When a patient comes to your office after cataract surgery, he's probably going to need refractive lenses. And if you want reimbursement, you-re going to need to unravel your DMERC's complex coding and billing rules. Lucky for you, we-re here to help.

Optometrists often describe Durable Medical Equipment Regional Carrier (DMERC) coding and billing as one of the most complex duties they perform. Coding for refractive lenses makes it even more complex, with the multitude of options available to patients combined with Medicare's strict coverage guidelines.

Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal, e.g., after cataract surgery, or who have congenital absence), says Christine Miller, coder for San Luis Obispo Eye Associates in California. Medicare covers one pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens. Your DMERC claim for refractive lenses must be linked to one of these ICD-9 codes to prove medical necessity:

- 379.31--Aphakia
- 743.35--Congenital aphakia
- V43.1--Organ or tissue replaced by other means; lens (pseudophakia).

Append KX for Doctor-Ordered Extras

The key to DMERC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code.

The prescribing physician must specifically order the special lens; it cannot be simply the patient's preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code, says Vicki Murphy, CPC, coder for Lake Eye Associates in Eustis, Fla. This modifier tells Medicare that you have documentation to support the medical necessity of the item you-re claiming.

Example: In most cases, Medicare will not pay for polycarbonate lenses (V2784). Patients often prefer polycarbonate lenses because they are sturdier and lighter than regular lenses. However, many optometrists prescribe polycarbonate lenses for patients with monocular vision, to help protect the remaining eye.

In these cases, report V2784-KX and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, -best corrected VA OS 20/400- should suffice, says Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.

Additionally, Medicare considers ultraviolet protection (V2755, U-V lens, per lens) reasonable and necessary after a cataract extraction. But you can only claim V2755 if the UV coating is applied to a glass or plastic lens. If UV protection is inherent in the lens material (as with polycarbonate lenses), you cannot report V2755 as an add-on code.

Carriers will deny claims for V2755 in addition to V2784 as not medically necessary.

Along with V2755 and V2784, Medicare will sometimes pay for these items, if they are medically necessary:

- Tints (V2744, V2745)
- Anti-reflective coating (V2750)
- Oversize lenses (V2780).

Use EY and GA for Patient Preferences

What if the prescribing physician did not specifically order an item, but the patient wants it anyway? Append modifier EY (No physician or other licensed healthcare provider order for this item or service) to patient- preference items, says David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas. -EY is the opposite of KX and is used on items that are sometimes medically necessary and sometimes not medically necessary,- he says.

Append modifier EY to V2744, V2745, V2750, V2780 and V2784 if the patient selects them without a specific order from the prescribing physician, says Palmetto's DMERC billing manual.

Noncovered items: There are a few HCPCS codes that your DMERC will never cover. Make sure that the Medicare beneficiary knows he is fully responsible for payment for noncovered items. Have him sign an advance beneficiary notice (ABN) and keep it on file. Append modifier GA (Waiver of liability statement on file) to these HCPCS codes, Miller says.

Although individual rules may vary, do not expect coverage from your DMERC carrier for the following:

- V2025--Deluxe frame
- V2702--Deluxe lens feature
- V2756--Eyeglass case
- V2760--Scratch-resistant coating, per lens
- V2761--Mirror coating, any type, solid, gradient or equal, any lens material, per lens
- V2762--Polarization, any lens material, per lens
- V2781--Progressive lens, per lens
- V2782--Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens
- V2783--Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens.

You don't need to append modifier EY to these HCPCS codes, Gibson says. -If an item is never approved, like V2025, then GA is the only modifier used,- he says.

You may also need to append modifiers LT (Left side) and RT (Right side). If you-re providing the same kind of lens on both sides, bill both on the same line of the claim form, append both LT and RT, and claim two units of service.

Example: Medicare will pay for trifocal lenses (V2300, Sphere, trifocal, plano to plus or minus 4.00d, per lens), but the patient wants anti-reflective coating (V2750) as well. On the claim form, report:

- V2300-RT-LT with two units of service
- V2750-RT-LT-EY-GA with two units of service.

Tip: -Most electronic claims can't handle four modifiers,- Gibson says. In those cases, omit EY. -We have never used EY, and we get paid what we should be paid for and are denied for those that should be denied,- he says.