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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
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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
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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
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