Ophthalmology and Optometry Coding Alert

Keep medical necessity distinct from patient preference in documentation.If you're providing refractive lenses for cataract surgery patients, you'll need to unravel your DME MAC's complex coding and billing rules to claim deserved Medicare reimbursement. The challenge: Ophthalmologists often describe durable medical equipment (DME) coding and billing as one of the most complex duties they perform. Coding for refractive lenses makes it even more complex, with the multitude of options available to patients combined with Medicare's strict coverage guidelines.Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal, e.g., after cataract surgery, or who have congenital absence). Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens, notes Joyce D. Ardrey, CPC, who led a seminar on billing for frames, lenses, and contact lenses at The Coding Institute's 2008 Optometry & Ophthalmology Coding and Reimbursement Conference. Most DME Medicare Administrative Contractors (DME MACs) specify that your claim for refractive lenses must be linked to one of these ICD-9 codes to prove medical necessity:• 379.31 -- Aphakia• 743.35 -- Congenital aphakia
• V43.1 -- Organ or tissue replaced by other means; lens (pseudophakia).Append KX for Doctor-Ordered ExtrasThe key to DME MAC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code. The standard benefit is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass, explains David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. If the patient or the doctor want more features, a modifier will be necessary on the claim.The prescribing physician must specifically order the special lens; it cannot be the patient's preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity of the item you're claiming.Example: In most cases, Medicare will not pay for polycarbonate lenses (V2784). Patients often prefer polycarbonate lenses because they are sturdier and lighter than regular lenses. However, many ophthalmologists prescribe polycarbonate lenses for patients with monocular vision to help protect the remaining eye. In these cases, report the lens with modifier KX (V2784-KX) and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, "best corrected VA OS 20/400" should suffice. "It doesn't need to go on the claim; just have it in the records," says Gibson.Additionally, Medicare considers ultraviolet protection (V2755, U-V lens, per lens) reasonable and necessary after a cataract extraction. [...]