Medicare Reimbursement for Post-Cataract Eyeglasses

Medicare does not usually pay for eyeglasses or contact lenses. However, if the beneficiary is aphakic (H27.0-),1 congenitally aphakic (Q12.3), or pseudophakic following cataract surgery (Z96.1), then glasses or contact lenses are a benefit under the portion of Medicare law covering prosthetic devices.2

These claims are frequently longer and more involved than claims for physicians’ services; attention to detail is very important. The proper codes must be identified, charges must be allocated carefully, and the patient’s responsibility for non-covered elements, deductible and co-payment must be carefully computed. These claims require specific information about the cataract surgery, including the date(s) of surgery and the operated eye(s). In addition, there are signature and forms requirements that do not usually arise in a medical practice. All the usual issues related to patient demographics continue to be concerns as well.

This document addresses the Medicare benefit for eyeglasses, including coverage and eligibility, rules governing billing and documentation, and enrollment requirements, which changed a few years ago. We also provide you with a series of examples, written with the assistance of an optician, so that you can see how this may work in your office. There are a series of forms and other references in the Appendix.

 

 

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1  Social Security Act, Sections 1862(a)(18), 1866(a)(1)(H)(ii), and 1888(e)(2)(A).

2  Social Security Act, Section 1861(w).

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