the business of contact lenses

CMS Coding Changes for 2010

BY CLARKE D. NEWMAN, OD, FAAO

Just when I thought I could leave medically necessary contact lens billing behind, Centers for Medicare and Medicaid Services (CMS) decides to make fundamental changes that affect the way we see these patients. Remember, Medicare covers contact lenses only in three instances—lenses used as a bandage, for aphakia, and scleral shells for dry eye (CMS National Carrier Determination [NCD] 80.1, 80.4, and 80.5). That hasn't changed.

A big misconception is that you cannot bill Medicare for any services when the contact lens services and materials are not covered. That is not true. When a provider sees a patient who does not need a bandage lens and who does not have aphakia or a severely dry eye, that provider can still bill Medicare for services associated with that patient except for the non-covered services.

Think of the contact lens services as being just like a refraction. You bill it, but the patient is wholly responsible for it. Therefore, we can still bill for all services for non-covered situations such as keratoconus patients.

Mind the Consultation Codes

Now for the big changes! In the past, if a patient was referred by another practitioner, and there was no obvious transfer of care, you could bill the E/M Consultation Codes (see my Coding Strategies column from June 2008). Some requirements had to be fulfilled such as writing letters in report, but you could use these codes to reflect the time and complexity involved in cases that could not be sorted out by other providers.

However, since Jan. 1, 2010, CMS no longer honors the Consultation Codes. CMS requires us to use the regular E/M Service Codes.

As an aside, the 2010 CPT preamble for the E/M Service Codes contains specific language about the transfer of care that heretofore was contained in the CMS Publication 100-4, Chapter 12, Section 30.6.10. The stricter CMS rules are now memorialized in the CPT rules so that they apply to all carriers rather than just to Medicare. Great, huh?

ABN Changes This Month

The other big change that started on April 1 has to do with Advanced Beneficiary Notices of Noncoverage, or ABNs (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6563.pdf). When you bill services that are non-covered, you are required in some instances to report those codes (www.cms.hhs.gov/MLN MattersArticles/downloads/MM6136.pdf).

For medically necessary contact lenses, we meet one of those tests—"Medical equipment and/or supplies denied in advance." The CMS NCD 80.4 states that services and materials associated with contact lenses are non-covered if they are associated with any diagnosis other than aphakia (www.cms.hhs.gov/manuals/ downloads/ncdl 03cl_Partl.pdf).

Therefore, when you file your claim for the covered services, you should also file the non-covered services and use the “-GA” modifier to report the mandatory disclosure of non-covered services. You should disclose those services and materials on the CMS R-131 form, which is available in English and Spanish (www.cms.hhs.gov/BNI/02_ABN.asp).

What is really new is that there is now a modifier, “-GX,” for voluntary notifications of services such as routine eye examinations.

Because there are non-covered services that we provide to Medicare recipients irrespective of contact lens services, we might be correct to assume that we need ABNs on most of our Medicare patients.

If you use a 92310 or a 92313 code for a Medicare patient, i.e., a Fuchs' patient after transplant, you should, according the CMS interpretations, file one of those codes using the “-GA” modifier, and then you should disclose the non-covered service to the patient with a CMS R-131. CLS

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Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is also a consultant or advisor to B+L.