Optometry Coding & Billing Alert

Question: I have gotten a denial from our DMERC for a patient's bifocal lenses post cataract surgery. We attached the diagnosis code the LCD required (V43.1), and appended modifiers LT and RT to the lens codes. Is there something I missed?


South Carolina Subscriber

Answer: In addition to coding two units of the bifocal lenses with modifiers LT (Left side) and RT (Right side) appended--for example, V2200-LT (Sphere, bifocal, plano to plus or minus 4.00d, per lens; left side) and V2200-RT (Sphere, bifocal, plano to plus or minus 4.00d, per lens; right side)--you are correct to include ICD-9 code V43.1 (Organ or tissue replaced by other means; lens [pseudoaphakia]) as a diagnosis.

But there are a few other common pitfalls that might cause your DMERC to deny a claim. Check your CMS-1500 form for these common errors:

Item 11 (Insured's policy group or FECA number): If Medicare is the primary insurance, enter the word -NONE.-

Item 14 (Date of current illness [first symptom]): Enter the date of the cataract surgery.

Items 17 (Name of referring physician or other source) and 17a (I.D. number of referring physician): Enter the name and Unique Physician Identification Number (UPIN) of the doctor who prescribed the lenses.

Item 19 (Reserved for local use): Enter the date of the surgery, and which eye was operated on.

Item 24a (Date of service): Enter the date you dispense the glasses.

Item 24b (Place of service): The POS should be where the beneficiary is residing, not the office. If the patient lives at home, the POS would be 12 (home), not 11 (office). Rationale: The patient will be using the lenses where he resides, not in your office. POS codes 31 (skilled nursing facility) and 32 (nursing facility) are also permitted.

Item 33 (Physician's billing name, address -): Enter your information here, along with the 10-digit NSC number you were issued by the National Supplier Clearinghouse (NSC). Your name and address also go in Item 32 (Name and address of facility where services were rendered).

Don't forget: Report V2020 (Frames, purchases) along with the lenses for the patient's eyeglasses. If the patient is purchasing frames more costly than the basic frames, report V2025 (Deluxe frame) along with V2020 for the excess beyond the basic-frame allowance.

Append modifier GA (Waiver of liability statement on file) and keep an advance beneficiary notice (ABN) in the record.

--Advice for Reader Questions and You Be the Expert contributed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas; and Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.