Medicare Reimbursement: Modifiers KX, EY keys to DME Reimbursement

Published: 23rd June 2011
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Providing refractive lenses for cataract surgery patients is it? Well, you will need to unravel your DME MAC's complex coding and billing rules to get yourself your deserved Medicare reimbursement.

Test: Often ophthalmology coders describe durable medical equipment (DME) coding and billing as one of the most complex duties they carry out. Coding for refractive lenses makes it all the more difficult with the multitude of choices available to patients combined with Medicare's strict coverage guidelines.

Medicare will only pay for refractive lenses for aphakic beneficiaries. Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens.

Add KX for doctor-ordered extras

The key to DME Medicare Administrative Contractor (DME MAC) payment for refractive lens features is medical necessity, and this calls for something more than just choosing the right ICD-9 code. The set advantage is a flat-top (FT) 25/28 bifocal/trifocal in plastic/ glass. If the patient or the doctor want more features, a modifier will be required on the claim.

The prescribing physician must order the special lens specifically. It cannot be the preference of the patient for one type of lens over another. If a doctor orders a particular type of lens or lens treatment specifically, you should add modifier KX to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity of the item you are claiming.

Use EY and GA for patient preferences

What happens if the prescribing physician didn't specifically order an item, however the patient wants it anyway; well you should add modifier EY to the patient-preference items.

If the patient chooses these items without a specific order from the prescribing physician, add modifier EY to HCPCS codes V2744, V2745, V2750, V2780, and V2784, according to DME MAC Noridian's local coverage decision (LCD) for refractive lenses. If the DME MAC will not cover an item, you're responsible for obtaining a singed ABN from the patient, and append modifier GA to the services you submit to the Medicare carrier. You should see to it that you provide the patient with a copy of the completed ABN and retain the original on file.

You should use modifier GA only to report when a required ABN was issued for a service and GA shouldn't be reported in association with any other liability-related modifier and should remain to be submitted with covered charges. To put it simply, the GA indicates that you've signed ABN on file. You may also require to add modifiers LT and RT. If you are providing the same lens on both sides, bill both on the same line of the claim form, add both LT and RT and claim two units of service.

For more on this and for other tips to get you your deserved Medicare reimbursement, sign up for a medical coding guide like Supercoder. Such a site comes with a Physician Coder's PowerPack to give everything you need for denial-proof claims.

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