Billing DMERC Post Op glasses

[rmcguirt]

We bill medicare postop glasses. We used a billing service in the past that is now defunct. We want to bill via CPM. It seems to present issues. Example: The same item number will invaribally need two(2) CPT codes. V2020 standard frame, and V2025 Delux frame.  How do you attach the different CPT codes to the same item? Example 2: Often more then one modifier will need to be attached to one CPT code. Say the patient wants PAL, but the doctor Rx'd UV. That would require 2 modifiers.

I would be glad to rtalk directly to someone. Thanks

[gracecrystalpm]

In my history of billing postop specs to Medicare, we would use V2020 or V2025 (not both) for a frame. Lenses will be separated out to RT LT so example: V2300 RT V2302 LT or in your case V2781 RT V2781 LT.

[lorie]

We have to use both codes to bill DMERC V2020 AND V2025, I manually add V2025 to the bill after correcting the charges. Being that you have to change the location code to a 12 in order for it to process correctly, I created a whole new set of codes for dmerc and I linked them to pull with the DMERC insurance company. I hope this helps

[rmcguirt]

You have  to identify and account for all of the charges for frames and lenses.

If the patient is getting the frame and only one lens, the lens for the non-operated eye must have modifiers to exclude it from DMERC, if the prescriber rx's UV you can bill it to DMERC, other wise you can't and it needs a modifier.  

Does DMERC filing become a manual operation, customized for each sale? Is CPM basically  weak in this area?

Here is a real life example: Many post op patients buy PAL's with ARC built in to the selling price. This requires the ARC to be subtracted out, the MC allowed for plastic ST28 to be broken out, the lens difference needs its own code and modifier, and the ARC with a modifier needs to be added back in. If you want to make it more complicated , soemtimes the patient buys just one lens, while the other lens is full price!  Yikes !  This gets difficult to do accurately or are we making it complicated. 

All help is appreciated.

[KizerOpt]

Sounds complicated. We don't bundle the add-ons in the cpt codes, so we bill the basic lens (v2203, for ex), then use the appropriate v-code for the add-ons. Makes it easier to build up from the bottom - frame, deluxe frame for overage, lens, add on for progressive, AR, etc. It becomes complicated when you make up codes for specialized items/options. If you stay close to the HCPS codes, it's easier. You can use the same CPT code for multiple items like deluxe AR, or value AR, 4 types of Transitions, etc and just use the description to see what it is. Hope this helps someone!

Karen

[rmcguirt]

OK  Thanks for the help. We are doing some of these things. Setting up the codes via the insurance tab would be tedious, but do-able; building fees  from the bottom up for MC (we are doing). Is there an accurate source of MC allowable on lenses and add-ons that you access?

[KizerOpt]

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

DME fee schedules. If this is not the right location for you, you can search for 2015 DME Fee Schedule.

Karen

[rmcguirt]

We are making head way. Thanks Lori, we set up medicare glasses as a separate insurance and and parceled out the dollar amounts accordingly.  Got current MC allowable from Karen's post. (There is a lot of info at CMS.gov BUT it's buried deep) Invariably post op Rx's are well inside the first division of powers (+/- 4 under 2 cyl etc), we made that our default lens code. We defaulted ARC's UV's tints, to patient pays, and will move charges to MC  should they be Rx'ed by provider.  We changed place of service to 12 for frame, lenses, etc. The notion is that the product is placed ion service in the patients home. I will monitor to see if other insurances object. Learned Rt and Lt lenses can be put on same line on HICFA 1500. Multiple modifiers (ga, rt, lt, etc) can all be put in on same line, when appropriate,  if spaced by a comma only. 

Feeling pretty good. Thanks for the help.  More as it develops.

GRM