Medicare Q&A

Special Lens Features 
For Special Needs

A. With so many specialty features available on ophthalmic lenses, you may get confused about what Medicare covers for cataract surgery patients. Medicare generally covers one pair of glasses after each cataract surgery (or as medically necessary for aphakic patients). However, it only covers such special features as tints, photochromic lenses and anti-reflective coatings when medically necessary. For example, a tint or UV coating would be medically necessary for a patient whose iris was torn during surgery and is now light sensitive. 

Still, each carrier has its own interpretation of medical necessity, says optometrist and Medicare lecturer K. Michael Larkin, of Fullerton, Calif. Your safest bet: Check with your carrier.

To bill Medicare for specialty features, use the appropriate code such as V2750 (anti-reflective coating) or V2755 (UV protection). No specific code exists for Transitions lenses, so you would bill the V2744 code (photochromic glass or plastic lenses). Use the -zx modifier to indicate medical necessity, and document the reasons in the patient’s chart

If the patient opts for features that aren’t medically necessary, have him or her sign a Medicare waiver, advises Auburn, Ind., optometrist Douglas C. Morrow, who conducts coding seminars. This waiver shows you told the patient in advance that Medicare would not cover these options and that the patient was responsible for the extra cost. 

If you use such modifiers as the -zx more often than other doctors in your area, you could be audited. Careful documentation remains your best defense.—Jeffrey S. Eisenberg
 

Do Your Homework Before 
You Bill For House Calls

A. There are no changes in the codes you would bill when you see a patient in his or her home (99341-99345, new patient; 99347-99350, established patient)-at least not at the national level or in CPT 2000. Some other considerations:

• Choose a level of service just as you would with other evaluation and management (E/M) codes. These too take into account such components as history, examination and medical decision-making. Also, you must document how much time you spent with the patient.
• If another doctor requests the visit, you might bill a consultation code (99241-99245). A letter from the referring doctor is the safest way to document why you’re billing these codes, and you must send a report letter back. For those reasons, H. Clif Gregory, O.D., of Barbourville, Ky., finds the home visit codes easier to use when he goes to a patient’s home. Also, he bills the code for cataract comanagement when he sees cataract patients in their homes.
• Use the correct place of service on the HCFA-1500 form. The correct place of service code is 12.
• Consider obtaining a referral from the patient’s primary care physician. Optometrist Michael Bacigalupi of Ballinger, Texas, uses a standard referral form before he makes a house call. “Medicare has never asked for that, but I don’t think it’s a bad idea to have that on file in case there are any questions,” he says.

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