According to the most recent information from CMS in 2022, there is a 66% error rate in SMRC audits for reimbursement of Durable Medical Equipment Post-Cataract Eyeglasses.¹

In the article below, we will discuss the action steps to best adhere to CMS requirements for ordering and dispensing post-cataract glasses. We will start by discussing the proper diagnoses codes that can be used for such glasses, before moving on to how to submit the related forms to Medicare.

1. Remember covered conditions/lenses
There are just 3 diagnoses that can be used on Medicare claims for post-cataract eyeglasses or contact lenses:

• Aphakia
• Congenital aphakia
• Pseudophakia

Furthermore, only eyeglasses and CLs provided by an enrolled supplier are covered, no matter who submits the claim. (For more information on what locations are considered enrolled suppliers, see sidebar “DMEPOS program.”)

2. Satisfy medical necessity
Also, don’t forget that ANY Medicare claim must satisfy the basic medical necessity requirements of the program.

Consequently, while the statute reads: “...one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens...”,² we also must consider medical necessity individually.

This is important because many ophthalmologists, optometrists, and opticians mistakenly believe that two pairs of glasses (frame and lenses) are always due to any patient after two cataract operations. 

Instead, if a patient has TWO cataract surgeries but gets eyeglasses ONLY after the second surgery, the beneficiary is ineligible to receive ANOTHER pair of glasses for the initial cataract surgery.

3. Code for covered features
There are a variety of V codes that can be used on your claim for post-cataract glasses (see Table).

TABLE: Examples of HCPSCS codes for covered features on post-cataract glasses

Patients who select “standard” frames receive a qualifying item, and the beneficiary is only responsible for the applicable deductible and copayment.

The HCPCS code for a standard frame is V2020, and the HCPCS code for the frame overage is V2025. 

Aside from the frame, features that are covered by Medicare include prescription lenses, slab off, prism, a balance lens, and wide segment bifocals or trifocals are all covered items. UV filtration is deemed to be medically necessary if the physician orders it, but only for lenses that do not have UV protection inherent in the lens material. Only polycarbonate lenses (not plastic or glass) are deemed to include UV protection. Polycarbonate is included in the larger category of all high-index lenses.

The explanation for ordering certain deluxe features will also require specific explanations. For example, trifocals may be needed for a patient who requires accommodation at near and intermediate distances.

You would use modifier KX for such “uncommon” items beyond basic frames and lenses that are medically justified.

Non-covered items would use modifier EY.

4. Inform patient of non-covered items
The Medicare beneficiary is financially responsible for noncovered items, such as the cosmetic features of a pair of eyeglasses, but only if the beneficiary is properly informed in advance. This usually occurs when the patient signs an Advance Beneficiary Notice of Noncoverage (ABN). HIPAA mandates this required form for all noncovered items. It informs the beneficiary that Medicare will probably deny reimbursement, explains why, and provides the expected cost to the patient. The patient is entitled to a copy of this form.

I recommend collecting full payment for the noncovered items before fabricating the eyeglasses.

When non-covered items are chosen by the patient, there are two claims.

The first claim contains only covered items, and the second claim contains only noncovered items. According to CMS:

For Coordination of Benefits purposes, DMEPOS suppliers should use the modifier EY (no order for this item or service) on each line item on the claim … submitted on or after May 23, 2008, to secure a Medicare denial.³

Also, use modifier GA with any noncovered item identified on the ABN.  

Modifier GA signifies that the optometrist has an ABN on file properly executed and signed. 

5. Review DME MAC’s required information 
Six forms generally apply in almost all cases for dispensing post-cataract glasses – that’s a significant amount of paperwork!

They are:

1)        Assignment of benefits form, also known as the signature on file. It’s required for each prescription you fill. 

2)        A written prescription that describes medically necessary items in detail.

3)        Advance Beneficiary Notice of Noncoverage (ABN) for any noncovered items.

4)        A signed delivery receipt.

5)        The Medicare official DME Supplier standards.

6)        A signature on file form containing standard language that permits the dispensary to file a claim for reimbursement.

The Social Security Administration states: “For any DMEPOS item to be covered by Medicare, the supplier must have an order from the treating physician before dispensing the item to a beneficiary. Items dispensed without an order from the treating physician will be denied as not medically necessary by the DME MAC…” ⁴

According to instructions published in the DME MAC manuals and bulletins, the physician’s order must also contain several specific items:

• Prescribing physician’s name
• Date of the order
• Patient’s name and full address
• Patient’s diagnosis
• Description of the items, either narrative or a brand name and model number
• All options and additional features that are separately ordered by the physician and will be separately billed
• Physician’s handwritten ink signature or electronic signature and date; note that a stamped or surrogate signature is not acceptable   

You must have a detailed written order before submitting a claim, which MUST identify exactly what is required and why. 

For example, a new frame may be needed because the current frame is too old, or perhaps the patient doesn’t presently have eyeglasses.

You cannot assume that a new frame is medically necessary.

6. Check your date and place of service
In my experience, two areas that often confuse reimbursement filers are filling out the “date of service” and “place of service” information.

Medicare instructs that the date of service is the date the patient receives the eyeglasses – NOT the date the eyeglasses are ordered.  In the extraordinary case when the patient died before receiving the eyeglasses, the date of death is used on the claim.

For those cases where the patient cannot pick up the glasses in person, the date of shipment is used on the claim. 

Medicare instructs that the place of service is where the patient will use the eyeglasses, typically the patient’s home, although it might be a nursing home instead. 

Oftentimes, the optician or biller will use the place of service where the eyeglasses were delivered. This is not correct, and it will cause problems with your claims.  

Providers must submit claims according to the beneficiary’s home address rather than the provider’s business address, and payment is based on the fee schedule in place in the beneficiary’s home DME MAC jurisdiction. For example, a beneficiary who resides in Rhode Island visits an optical shop in Massachusetts to purchase covered eyewear. The DME MAC for Region A will process the claim based on Rhode Island’s rates rather than Massachusetts’. If the same beneficiary purchased eyewear in Florida, the DME MAC for Region A would still process the claim rather than Region C, and Rhode Island’s rates would apply rather than Florida’s. You do not need to register with each region; one enrollment works for billing all four jurisdictions.

7. Provide proof of delivery
The Medicare Manual instructs providers that you must show proof of delivery for post-cataract eyeglasses. Without proof, there can be no reimbursement. 

This requirement is met by having the beneficiary sign a delivery receipt. 

This is not difficult to do. It is usually done on the optician’s paperwork, which includes the beneficiary’s name, a detailed description of the items and measurements, and the delivery date. This document must be kept for seven years.⁵

Sometimes the beneficiary cannot pick up the eyeglasses in person. In that case, use a delivery service such as UPS or the Postal Service.

You should include a business reply card for the patient to sign and mail back to you. If you receive a signed acknowledgment of delivery, use the signature date as the date of service.  If it is not possible to get a signed acknowledgment, use your shipping or mailing date as the date of service. In any case, use a service that allows you to track the parcel and keep the tracking information on file. 

On those rare occasions when the glasses become undeliverable, Medicare allows you to submit a claim to recover the expenses associated with producing the glasses. For this provision, acceptable reasons for non-delivery are generally limited to:

• Patient deceased prior to delivery.

• The patient’s medical condition changed, and the item is no longer medically necessary or appropriate.

To recover expenses associated with producing an undeliverable prosthetic device, such as eyeglasses, you must file a claim with the DME MAC. Use the date of death or the date you became aware that the patient’s medical condition changed as the date of service. Include an explanation of the circumstances with the claim.

Stay sharp
By now, you must realize that Medicare claims for post-cataract eyeglasses are complex, very detailed, and lengthy. Mistakes are common. There’s a lot of paperwork.

As we discussed above 66% of these claims contain errors, sometimes more than one.  The most common errors include incorrect places and dates of service, incorrect codes, billing violations and wrong copayment.   

This article should help improve your compliance with post-cataract DME claims. OM

References

1. 2022 Medicare Fee-for-Service Supplemental Improper Payment Data. CMS. Table D-1, G-2, I-2, and L-2. Accessed March 12, 2024.  Link Here
2. Social Security Act §1861(s)(8). Social Security Administration. Accessed March 12, 2024. Link Here
3. Center for Medicare and Medicaid Services. Medicare Processing Manual. Accessed March 12, 2024.  Link Here
4. SSA §1834(a)(11)(B), SSA §1861(s)(2)(K), 42 CFR 410.38, MPIM, Chapter 5, § 5.1.1 Link Here
5. Transmittal 61, Change Request 2903; January 2, 2004 Pub. 100-08 Medicare Program Integrity Link Here
6. CMS 855S Application. CMS. Accessed March 12, 2024. Link Here

Brandy H. Sperry, COMT, COE, CPC, CPMA is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext 238.