Modifiers KX, EY Vital for DME Reimbursement

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Providing refractive lenses for cataract surgery patients? Well, you will need to unravel your DME MAC's complex coding and billing rules to get your deserved Medicare reimbursement.

Many a time optometrists describe durable medical equipment (DME) coding and billing as one of the most complex duties they carry out. And coding for refractive lenses makes it even more complex with multitude of options available to patients combined with Medicare's strict coverage guidelines.

Medicare will only shell out money 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.

You should add KX for doctor-ordered extras

The key to DME MAC reimbursement for refractive lens features is medical necessity, and this involves more than just selecting the right ICD-9 code. The standard advantage is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass. If the patient or the doctor want more features, a modifier will be necessary on the claim. The prescribing physician must specifically order the special lens; it can't be the patient's preference for one type of lens over another. If a doctor specifically orders a particular type of lens or lens treatment, add modifier KX to the HCPCS code. This Medicare tells Medicare that you have documentation to support the medical necessity of the item you are claiming.

Make use of EY and GA for Patient Preferences

What if the prescribing physician didn't specifically order an item, however the patient wants it anyway? Well, add modifier EY to patient-preference items.

Add modifier EY to V2744, V2745, V2750, V2780, and V2784 if the patient selects these items without a specific order from the prescribing physician. If the DME MAC will not cover an item, you are responsible for obtaining a signed Advance Beneficiary Notice of Non coverage (ABN) from the patient, and adding modifier GA to the services you submit to the Medicare carrier. See to it that you provide the patient with a copy of the completed ABN and retain the original on file.

You may also need to add modifiers LT (Left side) and RT (Right side).If you are providing the same lens on both sides, bill both on the same line on the claim form, add both LT and RT, and claim two units of service.

You should watch for place of service (POS) errors

The place of service code you include on the claim depends on the patient's place of residence. For durable medical equipment, the POS is the place where the patient uses the equipment.

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