Optometry Coding & Billing Alert

Question: A patient presented for an exam three years after cataract surgery on both eyes. The surgery was done in another city and I was not involved in the post-op care. The patient said that he has not had any new glasses since the surgery. Should I file the claim to the DMERC carrier, or assume the patient is not being truthful and make him pay?


Arizona Subscriber

Answer: An advance beneficiary notice (ABN) is your best protection here. Medicare will only pay for one pair of glasses per patient after each cataract surgery.

If you are not sure if the patient has already used that benefit, you should have him read and sign an ABN, clarifying that he will be responsible for any part of your fee that Medicare does not cover.

Strategy: Append modifier GA (Waiver of liability statement on file) to the codes for the lenses and frames that you submit to the DMERC carrier. Modifier GA will not flag your claim for automatic denial; Medicare will review it like any other claim, and may or may not deny it.
 If Medicare does deny the claim because its records show that the patient has already received his post-cataract glasses, the patient will be fully liable to you for the cost.

Some optometrists collect the full fee from the patient up front; if Medicare pays the claim, the optometrists then reimburse the patient themselves.

For more information on modifier GA, download an information flier from CMS at www.cms.gov/medlearn/modchtga.pdf.