Medicare reimbursement form for glasses after cataract surgery

Excerpted from page 44 of the March 2018 edition of AOA Focus.

AOA's coding experts frequently receive questions regarding the appropriate coding for postoperative glasses. Here's what you need to know:

Coverage

Medicare will cover one pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with insertion of an intraocular lens (IOL). Replacement frames, eyeglass lenses and contact lenses are noncovered.

Frequency

Medicare will pay for one pair of post-cataract surgery glasses per lifetime per eye after cataract surgery. You also should review any local coverage determinations (LCDs) to find out if there are any local policy stipulations. Additionally, you also may want to call the Durable Medical Equipment Regional Carrier for your area to see if the patient is presently eligible for the glasses. Some LCDs clarify, "If a beneficiary has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, Medicare covers only one pair of eyeglasses or contact lenses after the second surgery. If a beneficiary has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye)."

Diagnoses to report

Payable diagnosis codes include:

• Z96.1 (pseudophakia)
• H27.01, H27.02, H27.03 (aphakia)
• Q12.3 (congenital aphakia)  

CPT codes to report

For one or two lenses, bill the correct Healthcare Common Procedure Coding System code (V21xx, V22xx, or V23xx) on separate lines for each eye; use modifier RT or LT and the fee for one lens at your standard fee.

Claims submission

If you are billing for eyeglasses or contact lenses, you should submit claims to your Medicare Durable Medical Equipment Administrative Contractor (DME MAC). Find a list of DME MACs.

Fees for DME suppliers

All suppliers of Durable Medical Equipment, Orthotics and Prosthetics (DMEPOS), including eyeglasses and contact lenses for postoperative cataract patients, are subject to an enrollment and revalidation fee. The AOA continues to advocate with the Centers for Medicare & Medicaid Services so that doctors who are enrolled in Medicare as physicians should be exempt from this fee.

To stay abreast of code changes and the latest coding information, access the AOA's coding resources:

• Online resources. For up-to-date codes and resources, access AOA's coding information at aoa.org/coding and AOA Coding Today.
• Got a coding question? If you have specific coding questions that are not addressed through AOA Coding Today, direct them to AOA's Coding Experts by completing the online form.
• Reference manuals. Purchase the 2018 CPT code bundle at AOA Marketplace.

If you have suggestions on how the AOA can best support the coding needs of doctors of optometry, please contact Kara Webb, AOA's associate director for coding and regulatory policy, by email or call 703.837.1018.

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• Medicare Post Cataract Surgery Reimbursement form?

1. 03-20-2013, 12:14 PM #1

   Medicare Post Cataract Surgery Reimbursement form?

   Does such a beast exist?

   Is there a form that patients can fill out and seek direct reimbursement from Medicare for their post cataract surgery specs?

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2. 03-20-2013, 12:34 PM #2

   

   OptiBoard Apprentice

   

   ---

   I'm very interested in this as well if anyone has had any success out there...

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3. 03-20-2013, 12:35 PM #3

   a place i used to work at filled out a CMS 1500 form for them, and sent it in for them so medicare would reimburse the patient. that way we didnt have to file it, and they could fight with the insurance company if they denied it

   

   it must be typed, then signed and dated by the patient!! and only sent in AFTER they have received the glasses, not before!!

   "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

   

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4. 03-20-2013, 12:37 PM #4

   http://www.cms.gov/Medicare/CMS-Form...0s-english.pdf but good luck with that, they are so picky it will probably never get paid.

   

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5. 03-20-2013, 12:42 PM #5

   also: there is no way to find out exactly what the patient reimbursement WILL be as far as i know.

   "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

   

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6. 03-20-2013, 12:46 PM #6

   We did this form for a customer and she just got denied because we were an "unknown supplier." She is resubmitting with our NPI # highlighted, so we'll see.

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7. 03-20-2013, 12:46 PM #7

   IhaveSpecialEyes is correct.

   Also, very important in mailing to correct address:

   Cigna Gov-Services
   P.O. Box 20010
   Nashville, Tenn. 3720200

   Hope this helps,
   TEdFitz

   ---

8. 03-20-2013, 12:52 PM #8

   https://www.noridianmedicare.com/dmefee/search.seam you should be able to get your reimburshment from this link.

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9. 03-20-2013, 01:36 PM #9

   a brief list of fun reasons that they'll deny claims:

   ~no four digit zip code after the 5 digit one
   ~place of service must be "office"
   ~diagnosis must be v43.1
   ~referring doctor must be the surgeon

   these are just the most recent reasons we've been getting claims that are denied, the list will continue to grow

   "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

   

   ---

10. 03-20-2013, 01:58 PM #10

    Usually the 3 codes that must be on the claim are 367.4, v43.1, v45.6.

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11. 03-20-2013, 02:01 PM #11

    

    Originally Posted by SeaU2020

    

    Usually the 3 codes that must be on the claim are 367.4, v43.1, v45.6.

    we had one get denied recently because we used more than one? but maybe thats just the excuse they had picked that day

    

    "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

    

    ---

12. 03-20-2013, 02:04 PM #12

    

    Originally Posted by TEdFitz

    

    IhaveSpecialEyes is correct.

    Also, very important in mailing to correct address:

    Cigna Gov-Services
    P.O. Box 20010
    Nashville, Tenn. 3720200

    Hope this helps,
    TEdFitz

    Depends on your state, in the northwest, ie Washington and I believe Oregon, may be others as well, we send the 1500 form to Noridian as IhaveSpecialEyes has linked in her last post.

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13. 03-20-2013, 02:09 PM #13

    Am I correct in thinking that you must be a medicare supplier to submit the form for the patient? An NPI number alone is not enough?

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14. 03-20-2013, 02:16 PM #14

    There is a previous thread on here that mentions that the form can only be used once? Is that correct?

    http://www.optiboard.com/forums/show...e-Optical-Shop

    Thank you all for the help!

    ---

15. 03-20-2013, 02:17 PM #15

    

    Originally Posted by EyeCare Rich

    

    Depends on your state, in the northwest, ie Washington and I believe Oregon, may be others as well, we send the 1500 form to Noridian as IhaveSpecialEyes has linked in her last post.

    Is the 1500 form better to use than the CMS-1490S form?

    ---

16. 03-20-2013, 02:17 PM #16

    ...attached to itemized bill of services rendered with tax id #, supplier mailing address, supplier physical address, and finally, proof of that unicorns exist.

    This IS a beast!

    ---

17. 03-20-2013, 02:23 PM #17

    Since @fezz has brought up this lovely insurance topic anyway, does anybody know about them covering AR, progressives, and transitions? we have always been told *and told the patients* that medicare will cover the cost of a basic FT-28 and $50ish dollars on their frame, all of the overage (i.e. poly and up, trans, ar, prog upcharge) comes out of their pocket. But then one of our billing people told us this may not be the case anymore? bueller??

    /hijackedsorryfezz!

    "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

    

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18. 03-20-2013, 02:40 PM #18

    Reimbursement usually involves around 44 dollars, per lens, per eye(s) that has had the surgery...Up to 60 dollars for a new frame. Next, throw into the mix a secondary insurance, a patient might get more.

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19. 03-20-2013, 04:08 PM #19

    At this point in time Medicare in my region is "Allowing" $74.37 (V2020 Standard Frame) toward a frame. (notice I did not say they are paying. They generally pay 20% less then what they "Allow") so we really end up getting $59.49 for a frame. The patient pays us the difference between $74.37 and what the frame sells for. (V2025 Deluxe Frame). The 20% that Medicare does not pay we submit to patients secondary insurance. If they do not have a secondary eventually they will get a bill for what does not get paid for by any insurances.

    For lenses Medicare only allows for bare bones CR-39 and FT-28 bi or trifocals. Sometimes we can get them to pay for a Ft-35 bi or tri after we struggle with it. But NO extras of any kind. No tint, no thinner light weight lenses, no progressive, no transitions all of the "Extras" are on the patient. Medicare will pay toward UV. How much they will pay towards the lenses is based on what the Rx is. It is selected from the V-code chart.

    As I understand it and the way we file it is AFTER cat. SX the patient will have one year to take advantage of Medicare benefits. ONE, yes I said ONE frame only. And if vision changes as the eye heals you might get a second set of lenses if needed. Our experience has been that Medicare will not pay for a frame if it does not have Rx lenses put into it. If the pt comes out of SX not needing any glasses and wants to buy a pair of PL Costa's, Maui Jim, Ray Ban sunglasses or any other kind Medicare will not pay for that.

    We have had to fight them tooth and nail just to get payment on the basics. We cannot collect any money from the patient for their share until the day they come get their glasses. It seems as though Medicare looks for any reason to reject the claim or ask for more more information to delay payment and keep the money in their bank longer. This being a OM D's office with a dispensary we have no choice but to file for the patient.

    "And that's how it is" at this office in Panama City Florida.

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20. 03-25-2013, 04:06 PM #20

    

    Master OptiBoarder

    

    ---

    

    Originally Posted by CME4SPECS

    

    Am I correct in thinking that you must be a medicare supplier to submit the form for the patient? An NPI number alone is not enough?

    Yes, you are correct. They will not reimburse a patient.

    Bev Heishman, ABOM, NCLC-AC

    ---

21. 03-25-2013, 04:17 PM #21

    

    Originally Posted by Bev Heishman

    

    Yes, you are correct. They will not reimburse a patient.

    
    Is this across the board or are there circumstances when they will reimburse the patient directly?

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22. 03-25-2013, 05:04 PM #22

    The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.

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23. 03-25-2013, 05:11 PM #23

    

    Originally Posted by TEdFitz

    

    The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.

    
    Thanks for confirming that. Any idea on the post that I made where I referenced that a patient could only use that once?

    This is a BEAST. A big PIA BEAST!

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24. 03-25-2013, 05:18 PM #24

    Once. Might be in the pt.'s interest to wait on filing until both eyes are done, w/in reason. Think of it this way: 2 pieces of paper, an envelope, and a forever stamp. Hand to patient. Wash hands.

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25. 03-25-2013, 06:03 PM #25

    where is this form that you are talking about?
    

    

    Originally Posted by TEdFitz

    

    The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.

    ---

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