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DME Post-op Glasses Claims • What is Medicare DME? Do I want to be a

provider?• How to sign up to be a DME supplier

• PECOS and Accreditation

• How to file clean DME claims with Noridian • What surgeon and surgery information must be included• What three diagnoses are acceptable on a DME claim • What narrative information is required on all Medicare

post-op claims • How to file each claim line • What modifiers are required

• Additional resources available 

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What is Medicare DME

• DME: Durable Medical Equipment supplied to Medicare Recipients• Wheelchairs• Oxygen• Refractive Lenses to replace the missing

crystalline lens of the eye• Post Cataract surgery• Congenital absence

• Many, many other items

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Who Manages Medicare DME

• DME Suppliers managed by the National Supplier Clearinghouse (NSC), currently administered by PalmettoGBA.

http://www.palmettogba.com/palmetto/Providers.nsf/vMasterDID/7SFLC76127?opendocument

• DME Claims handled by our DME carrier, Noridian Administrative Services.

https://www.noridianmedicare.com/dme/index.html

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Refractive Lens Coverage

In General, Medicare DME covers…• Patient with implanted IOL after surgery

• One pair of glasses after each cataract surgery• One set of contact lenses after each cataract surgery

• Patient without implanted IOL• Aphakic glasses, replaced when medically necessary• Aphakic contact lenses, replaced when necessary• Combinations of the above

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Refractive Lens Coverage

• Noridian web site on coverage of refractive lenses has two resources regarding eligibility, restrictions, and coding regulations• Local Coverage Determination (LCD) [13 pages]

https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.pdf

• Refractive Lens Policy Article [5 pages]https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/refractive_lenses_policy_article_-_effective_10-1-09.pdf

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Noridian LCD on Refractive Lenses

https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/refractive_lenses_lcd_-_effective_10-1-09.pdf

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Noridian Policy Article on Refractive Lenses

Policy Article Source: https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_articles/

refractive_lenses_policy_article_-_effective_10-1-09.pdf

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DME Refractive Lens Coding

• What you must have on file before you can file a claim with Noridian………….

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Before submitting a claim to DME, the supplier must have on file

• A written order (complete description). • Must be signed and dated by the treating

physician;

• A properly executed beneficiary authorization for assigned claims;

• A proper advance beneficiary notice (ABN) if a covered item is personal preference (not ordered by the physician)

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DME Written Orders

• DME states a written order must contain:• Beneficiary’s name and full address

• Complete detailed description of the item

• All options or additional features which will be billed separately

• Signature of physician (OD or MD)

and date signed

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Order Form:

Quentin Quack OD 1/1/05

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http://www.cms.hhs.gov/BNI/02_ABN.asp

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Before submitting a claim to DME, the supplier must have on file

• Proof of delivery;

• DME (DMEPOS) Supplier Standards should be given to patient & duplicate documented in record.

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(Proof of Delivery)

Received by _________________ Date __________

Patient Signature

Order Form:

Quentin Quack OD 1/1/05

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Medicare DME Supplier Standards

• The Durable Medical Equipment Supplier Standards must be followed closely by the supplier, and a copy of the standards must be given to the patient.

https://www.noridianmedicare.com/dme/enroll/25_standards.html

•Read them

•Follow them

•Give copy to patient

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Medicare DME Supplier Standards

• Standards 6: Be sure to document any warranty coverage.

• Standard 9: Make sure your phone listing matches your information on your NSC enrollment.

• Standard 12: You must document delivery of Rx, and also explanation of proper care of Rx.

• Standard 16: A copy of the standards must be given to patient, and you must document that you have done so.

• Standard 19: Make sure to have a written complaint protocol on hand.

• Standard 20: Keep a copy of complaints

Pp. 8-9. . April 2009

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Before submitting a claim to DME, the supplier must have on file

• Medical records supporting that the refractive lenses are necessary to restore vision normally provided by the natural lens of the eye because the patient has: • Pseudophakia (ICD-9 V43.1); or

• Aphakia (ICD-9 379.31); or

• Congenital Aphakia (ICD-9 743.35).

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Basic Rules of DME Coding

• Filing a DME claim with Noridian…the basics found at:

https://www.noridianmedicare.com/dme/claims/cms1500_08-05_tutorial.html

• Specific Rules for Refractive Lens coding on following slides…

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DME Claims for Cataract Post-op Glasses

• Box 17 (Name of Referring Physician)• The surgeon’s name, no abbreviations

• Box 17b (NPI)• The surgeon’s NPI

• Box 19 (narrative section)• ? The date of the surgery

• ? Which eye was operated upon

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BOTTOM CMS-1500 Referring Dr. Data

Referring Doctor“John Smith MD”

Referring Doctor’sNPI

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BOTTOM CMS-1500 Qualifying Information

Example: Date assumed + date relinquished post-op care

+ # Post-op care days.

Date of Surgery: MMDDYYYY Eye operated: RT or LT

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DME Claims for Cataract Post-op Glasses

• Box 21 line 1 (diagnosis)• Usual diagnosis: V43.1 pseudophakia• Also: 379.31 aphakia, 743.35 cong. aphakia

• Box 24, Line 1, Column A (date of service)• Date glasses were delivered

• Box 24, Line 1, Column B (location of service)• 12 [indicates location of use is at home]

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BOTTOM CMS-1500 Claim lines

V43.1

Date of Delivery

12

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DME Claims for Cataract Post-op Glasses

• Box 24, Line 1, Column D (CPT code)• V Codes for materials• Example: V2020 [frame]• Example: V2304RT [trifocal lens for right eye…no

spaces or dashes]

• Box 24, Line 1, Column F (charges)• Your total usual and customary charge for that item

(including customary dispensing fee or markup)

• Box 24, Line 1, Column J• Supplier’s NPI

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From Noridian LCD

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BOTTOM CMS-1500 Charges/Fee Data

1

V-codes with modifiers

Usual and customary fees charged (based on “per lens”)

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RT and LT Modifier

• Use RT and LT modifier on all HCPCS codes except frame codes. • Lenses

• Tints

• Everything except frame

• Lenses provided bilaterally should use the RTLT modifier & units of 2.

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V-Codes and Modifiers

• V-codes are the same as used for Medicaid and other 3rd parties

• Some DME Modifiers are the same as other 3rd Parties

• Some DME Modifiers are unique to DME

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BOTTOM CMS-1500 Service & Materials Supplied

RTLT FOR BOTH EYES – UNITS OF TWO

V2750EYGARTLT 2

V2744EYGARTLT 2

V2780EYGARTLT 2

V2784EYGARTLT 2

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BOTTOM CMS-1500 Service & Materials Supplied

RT FOR OD ONLY; LT FOR OS ONLY– UNITS OF

ONE V2750EYGART 1

V2750EYGALT 1

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DME Written Orders and Unique Modifiers

• Regarding the following lens features…• V2750 anti-reflective coating

• V2744, V2745 tints (transitions &none-sunglass)

• V2780 oversized lenses

• V2784 polycarbonate lenses (monocular vision)

• DME wants to know..• Was the extra NEEDED, and ORDERED

• Or, was is a PATIENT PREFERENCE item

DOCTOR’S ORDER

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DME Written Orders and Unique Modifiers

• If feature is specifically ordered by a physician (OD or MD) • V2750 anti-reflective coating• V2744, V2745 tints (transitions &none-sunglass)• V2780 oversized lenses• V2784 polycarbonate lenses (monocular vision)

• Written order should clearly indicate Dr. ordered it; claim should indicate by using the KX modifier

• Documentation for the need should be available on request.

DOCTOR’S ORDER

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BOTTOM CMS-1500 Service & Materials Supplied

•V2750KX

•V2744KX

•V2780KX

•V2784KX

KX MODIFIER WHEN ORDERED BY DOCTOR

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DME Written Orders and Unique Modifiers

• If one of the following lens feature is NOT ordered by a physician but is personal preference • V2750 anti-reflective coating• V2744, V2745 tints (transitions &none-sunglass)• V2780 oversized lenses• V2784 polycarbonate lenses (monocular vision)

• Claim should indicate it was personal preference by using the EY modifier

• ABN (advance beneficiary notice) should be obtained, • GA modifier should also then be used.

DOCTOR’S ORDER

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BOTTOM CMS-1500 Service & Materials Supplied

•V2750EYGA

•V2744EYGA

•V2780EYGA

•V2784EYGA

EY MODIFIER WHEN PATIENT PREFERENCE

GA MODIFIER WHEN ABN SIGNED BY PATIENT

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None-Covered Items

• None-covered means NEVER covered• V2760 Scratch resistant coating

• V2781 Progressive lenses

• V2025 Deluxe frames

• A non-covered item is the patient’s responsibility.

• Use the GY modifier on non-covered items

• Assures that the patient’s Medicare Remittance Advice states patient is responsible for payment.

XXXXX

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BOTTOM CMS-1500 Service & Materials Supplied

•V2025GY

•V2760GY

•V2781GY

GY MODIFIER WHEN NONE COVERED ITEM

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Deluxe Frames & Lenses

Frames.• V2020 first line of claim.

• V2025 second line of claim.

• The dollar amount for V2025 should be the difference between U&C deluxe charge and standard frame charges.

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Deluxe Frames & Lenses

Frame Example.• Deluxe Frame U&C $150.

• DME Allowed for basic frame $59.58.https://www.noridianmedicare.com/dme/fees/index.html

• Difference for V2025 is $90.42.

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BOTTOM CMS-1500 Service & Materials Supplied

DELUXE FRAME V2025 IS DIFFERENCE FROM U&C

V2020 5200

V2025GY 9800

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Progressive Lenses

• V2200-V2299 first line of claim (Bifocal codes), or

• V2300-V2399 first line of claim (Trifocal codes)

• V2781 next line of claim• The dollar amount for V2781 should be the

difference between the first line of claim and your U&C progressive charge

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Progressive Lenses

• EXAMPLE:

• V2203 bifocal pays $47 per lens ($94)https://www.noridianmedicare.com/dme/fees/index.html

• U&C for Progressive in your office $300

• V2781 equals $206

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BOTTOM CMS-1500 Service & Materials Supplied

PROGRESSIVE ADD V2781 IS DIFFERENCE FROM U&C

V2203RTLT 9400 2

V2781GY 20600 2

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UV Protection

• Covered on Glass lens

• Covered on Plastic if less than 100% UV protection• Document type of plastic lens used,

• Document less 100% UV protection.

• Maintain a table of various plastic lenses w/ UVA & UVB protection.

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UV Protection

• Every DME patient record should contain• Their lab invoice listing the type of plastic lens

supplied

• A copy of table with the lens type circled & UVA and UVB protection

• This protocol is not in LCD; Presented at a DME workshop in Omaha

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BOTTOM CMS-1500 Service & Materials Supplied

•V2755KXKX WHEN UV COAT ORDERED BY DOCTOR

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Filing two claims for the same DME patient prescription

• All items ordered by the physician are filed on one claim, with the referring physician’s name and NPI being listed in box 17 and 17b.

• All none-covered items and personal preference items are filed on a separate claim (at the same time), with the box 17 and 17b containing the DME supplier’s name and NPI.

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KX, EY, and GA Modifiers

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KX, EY, and GA Modifiers

Pg.9. August 2009

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References

• Noridian is our DME MAC Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC)

• NAS: Noridian Administrative Services, LLC • https://www.noridianmedicare.com/dme/index.html

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References

• NAS DME Supplier Manual • Documentation required

– Written order– Proof of Delivery– ABN– Supplier Standards

• Claims Submission• V-codes• Pricing

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References

• DME Happenings • DME Carrier newsletter

• Changes in CMS policy

• Updates in coding requirements

• Updates on documentation needed

• FAQs

• Changes in contact information

• Changes in Billing Requirements

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https://www.noridianmedicare.com/dme/

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https://www.noridianmedicare.com/dme/

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ELECTRONIC CLAIMS:Noridian CEDI Electronic Data Interchange

Information Bulletins

• If file with Noridian electronically, must go through CEDI• CEDI Puts out a plethora of bulletins each month

regarding the new common electronic data interchange • CEDI Will remove providers from database if inactive for

13 months.

PG.4. February 2009 September 2009

https://www.noridianmedicare.com/dme/claims/edi.html

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Recent DME Challenges• Accreditation

Requires none-degree holding suppliers to obtain accreditation from official accrediting body (initial cost $2500; and ~$1000 per year)

• Surety BondsRequires some suppliers to obtain a $50,000

surety bond (costs $500-$1500 per year)

• PECOS Medicare DatabaseMedicare’s database of providers and suppliers.

Must be kept up-to-date by you.

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Accreditation and Surety Bonds

• The DMEPOS surety bond and accreditation requirements have been the subject of several CMS bulletins and health care provider trade publication articles.

• ODs do not need accreditation.

• ODs do need surety bonds in some circumstances

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When Surety Bond is Needed

A DMEPOS surety bond is needed by an ODs if s/he

• Fills outside Medicare post-op RXs w/o exam

• Sells any DME other than post-op glasses or CLs

• Has an optician that is registered with DME

• Filled out their 855S enrollment incorrectly (PECOS)

• Their dispensary has a different tax ID number

http://www.palmettogba.com/Palmetto/Providers.nsf/files/suretybondfaqs09102009.pdf/$FIle/suretybondfaqs09102009.pdf

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Medicare PECOS Database

• To Avoid Claim Denial, Make Sure that You, and All Providers that Refer to You, Are In the Medicare PECOS System

http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf

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Online PECOS• You must have updated your PECOS enrollment since 2003

• If a referral or an order is involved in any claim, both PECOS enrollments (“referred by” Dr. and “referred to” Dr.) must be updated and correct.

• According to CMS, physicians can usehttps://pecos.cms.hhs.gov/pecos/login.do to check whether they are in PECOS

• As of May, CMS claimed that online enrollment is “twice as fast” as paper PECOS enrollment. (not for original enrollment, however.)

http://www.wpsmedicare.com/j5macpartb/publications/communique/current/_files/1009comm.pdf

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PECOS Claim Requirements

• If a referring or ordering provider is included on a DME claim, (areas 17 & 17b), then:1. That provider and his/her NPI must be in the PECOS

system;2. The provider’s name must be in all upper case;3. Use no abbreviations or nick-names;4. Do not proceed name with “Dr.”5. Look for the referrer in PECOS system (available soon)

before providing service.6. Otherwise, claim will be denied.And you cannot bill the patient.

http://nebraska.aoa.org/prebuilt/noa/2009-11-3RD-PARTY-NEWLSETTER.pdf

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That’s all, Folks!!

Dr. Quack