Post-cataract Eyeglasses Billing Changes

Effective for claims submitted as of May 23, 2008, there is a change in the way you will bill Medicare for post-cataract eyeglasses. The change is due to NPI claim requirements.

Readers will remember that Modifier EY indicates that an item is non-covered because it was not ordered by a physician. This pertains to those features of eyeglasses that are patient preference, including most tints, scratch coating, anti-reflective coating, and polycarbonate lenses for appearance and light weight. These are the upgrades that patients elect to receive that are not medically necessary.

On April 1, 2008, CMS published a MedLearn Matters bulletin (MM5771) on this matter.

With the implementation of NPI billing, it is now necessary to bill covered services on one claim and non-covered services (with modifier EY) on a separate claim.

The bulletin states:

For Coordination of Benefit purposes, DMEPOS suppliers should use the modifier EY (no physician or other licensed health care provider order for this item or service) on each line item on the claim and report their own name and National Provider Identifier (NPI) in the “Ordering/Referring Provider Name” fields on claims submitted on or after May 23, 2008 to secure a Medicare denial. Failure to include the EY modifier on all line items will result in return of your claim as unprocessable. On such returned claims, the Medicare contractor will include Reason Code 4 to show that “The procedure code is inconsistent with the modifier used or a required modifier is missing.”

If you have obtained a physician’s order for some, but not all, of the items provided to the Medicare beneficiary, submit a separate claim for the items dispenses without a physician’s order. [emphasis added]

This will change the way you submit claims, but should not affect patients since they are already being informed about covered vs. non-covered items.

The original instruction, CMS transmittal (CR5771), issued to the Medicare DME MACs is available at http://www.cms.hhs.gov/Transmittals/downloads/R1368CP.pdf.

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