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There has not been muchchange in the wayMedicare reimburses forglasses or contact lenses.Coverage is permitted only

when the patient has had cataractsurgery with or without an intraocu-lar lens implant (IOL), an IOLexchange, or secondary IOL implan-

tation, or in the patient who has acongenital absence of the lens. Thereare only three covered diagnoses forglasses—aphakia, pseudophakia, andcongenital aphakia. Here are a fewrules the optical shop has to followin order to receive payment fromMedicare.

Documentation of Cataract Surgery orCongenital AphakiaThe most basic of the rules is thatthe optical shop must document thedate of the cataract surgery in thechart and indicate it on the claim.Usually, the surgical patient willhave a copy of the IOL card with the

Optical Shop Billing UpdateHeather B. Freeland

Here are a fewrules the opticalshop has to followin order to receivepayment fromMedicare.

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date of the surgery. If the opticalshop can only determine the monthand year of the surgery, it will be suf-ficient. Patients who had cataractsurgery before they were eligible forMedicare are permitted to use theMedicare prosthetic benefit.

The congenital aphakic patientwill not need a date of surgery sincethe patient never had a natural lens.The medical documentation of thecondition is all that is necessary tosupport the need for glasses.

The PrescriptionA prescription or order from thetreating physician is required beforepost-cataract glasses or contacts canbe reimbursed by Medicare. The pre-scription must have a description ofthe item (glasses or contacts), thepatient’s name, the name of theordering physician, and the date ofthe order. The prescription for thenew glasses must be an original pen-and-ink signed document (it must beportable). The ordering physicianmay not use a stamped signature norcan a surrogate sign the prescriptionfor him. The durable medical equip-ment Medicare administrative con-tractors (DME MACs) have indicatedthat if the prescription is not in thechart when the claim for the glassesis submitted, the claim will bedenied as not medically necessary.

The prescription must bedetailed enough for the DME MACto determine medical necessity. Themanifest refraction and special visualneeds of the patient must be notedon the prescription. Besides the spe-cific refractive lenses required by thepatient, the prescription should spec-ify which special features, if any, thepatient needs and give a brief reasonwhy the item is medically necessary.If the special feature is not listedwith the medical reason on the pre-scription, Medicare will deny theservice as not medically necessary.

The Date of Service Is the Date of DeliveryAs with all Medicare covered servic-es, the date of service must be docu-mented in the optical shop chart.All prosthetic devices must be pre-scribed on or before the device isfurnished. The glasses, however, can-not be billed to Medicare until thepatient receives them. The date theglasses are ordered cannot be sub-mitted as the “date of service” toMedicare.

The date of service will be theactual date the patient received thenew glasses, or the date a personsigned for and accepted the deliveryof the glasses on behalf of thepatient, or the date the glasses wereshipped to the patient. Please notethat if someone other than thepatient accepts delivery of the glass-es, the relationship of that person tothe patient should be indicated onthe receipt.

The Suppliers Standards requirethe optical shop to have proof ofdelivery on file. The proof of deliv-ery can be a receipt of payment thatincludes a description of the glasses,the patient’s name and signature,the date of delivery, and the nameof the optical shop.

The GlassesThe glasses prescription is good forone pair of glasses or contacts aftereach cataract surgery date. Each pairof glasses includes a standard con-ventional frame and two standardconventional lenses.

The pseudophakic patient couldreceive coverage for two pairs ofglasses after having cataract surgeryon both eyes—one pair after eachprocedure. If the pseudophakicpatient waits until after the secondeye surgery to order the post-opglasses, Medicare will only cover onepair of glasses. Also, should patientschoose to use their old frames andjust get new lenses, Medicare will

not reimburse for frames bought at alater date.

The aphakic patient can pur-chase a pair of lenses or a combina-tion of lenses whenever it is med-ically necessary. Patients may neednew glasses because their visionchanged or they have broken or losttheir glasses. The optical shop isrequired to fully document the rea-son for the special circumstances ofreplacing the aphakic glasses.

A prescription that is detailedand lists any special visual needs ofthe patient is required for each pur-chase. The aphakic patient canchoose to purchase (1) a pair of bifo-cal or trifocal lenses in frames, (2)one pair each for distance and nearvision, or (3) contact lenses withone pair of near vision glasses to beworn at the same time as the con-tacts, with a pair of glasses to beworn without the contacts.

Covered Special FeaturesMedicare allows payment for certainspecial visual needs items that areprescribed by the treating physician.Such special items are tints (includingphotochromatic), oversized lenses,anti-reflective coating, and impact-resistant lenses. Documentation mustbe present in the record to supportcoverage for each item.

If a special feature is notordered by the physician, the DMEMAC will determine the item as apatient’s preference item and willdeny the feature as not medicallynecessary. When the special item isspecifically ordered by the treatingphysician and there is documentationto support the medical necessity ofthe lens feature in the patient’s chart,the -KX modifier, “Requirementsspecified in the medical policy havebeen met,” should be added to thesespecial items.

UV coating is now recognized asa medically necessary feature forpost-cataract patients. It is only cov-

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ered if the coating is applied to lens-es and not as an add-on for lensesalready having inherent UV protec-tion. The UV coating must be specif-ically listed on the prescription inorder to be covered by Medicare.

If the order does not includemention of the special item but thepatient purchases it and insists thatthe optical shop bill Medicare, theitem must be identified with the -EYmodifier, “No physician or otherlicensed healthcare provider order

for this item or service.” In order forthe optical shop to collect from thepatient for the item, the patientmust also be given an advance bene-ficiary notice, form CMS-R-131, thatthe special item will be denied forlack of medical necessity (no order).The -GA modifier will tell Medicarethat the patient was notified inadvance of the non-coverage.

Personal preference and non-covered items are billable directly tothe patient. These items do not have

to be billed to Medicare unless thepatient insists. When filing a claimto Medicare, the personal preferenceitems must be filed on a differentclaim from the items listed on theprescription and dispensed. The rea-son is that these special items werenot ordered by a physician andtherefore Items 17 and 17a of theCMS-1500 form, or electronic equiv-alent, must be blank.

Finally, Accreditation and Surety Bonds Ophthalmologists, optometrists, andopticians are exempt from needingto get accreditation if they only pro-vide the normal range of suppliesand service within their specialty.Any products or services providedoutside the normal range of servicesrequire accreditation to maintainMedicare billing privileges as suppli-ers of glasses.

Similarly, an ophthalmologist oroptometrist who dispenses eyeglassescan qualify for the surety bondexemption if the glasses are fur-nished only to his/her own patientsas part of his/her own service. Theterm “own patient” does not includea person who walks into the opticalshop with a prescription for glassesthat was issued by another physicianand simply receives the glasses with-out any sort of examination or testbeing furnished. AE

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Karen Butler, COEPractice AdministratorCrew Eye Center

� The first time that I attended the ASOA Congress, I was happily over-whelmed by all the courses. I soaked up so much information and my doc-tor was amazed by all that I had learned. I have been attending for yearsand the content remains incredibly valuable. There is always new subjectmatter to learn about in ophthalmic practice management. Another advan-tage to the Annual Meeting is connecting with my colleagues, who I meetthrough EyeMail. The Annual Meeting provides an important networkingopportunity, which allows me to further brainstorm with other administra-tors and consultants. Now it’s a given that I will attend each year becausemy doctors see the huge benefits of the knowledge that I attain throughthe ASOA Congress and how this experience will improve the practice.�

March 25–29, 2011

Heather B. Freeland (800-720-9667; results@roseandassoci-ates.com) is the director ofcoding and compliance atRose & Associates inDuncanville, Texas. Rose &Associates is a nationally rec-ognized healthcare consultingfirm specializing in Medicarereimbursement and compli-ance for the specialty of oph-thalmology.