Are you thinking of expanding your optometry practice’s services to include co-managing cataract surgeries? Make sure your dispensary is compliant with Medicare payment rules for post-cataract eyeglasses. Otherwise, you could be losing out on eyewear revenue and fully caring for your patients.
Medicare Coverage of Post-Cataract Eyeglasses, Explained
You may already know this, but it’s worth emphasizing: Medicare does not cover refractions, eyeglasses, or contact lenses for beneficiaries. The exception is for post-cataract surgery or in cases when surgery results in the removal of the eye’s natural lens.
Whether the patient has an Intraocular Cataract Lens (IOL) implant determines the extent of Medicare glasses coverage. CMS states that “One pair of conventional eyeglasses or conventional contact lenses furnished after each cataract surgery with insertion of an IOL is covered,” according to the Medicare Benefit Policy Manual, Ch. 15. “Covered Medical and Other Health Services,”§ 120.B.3.
Given this directive, it would appear a patient who has had cataract surgery on one eye and is waiting to have the second eye done could qualify for post-cataract eyewear after the first surgery and an additional pair of Medicare-covered glasses after the second.
Billing for Post-Cataract Eyeglasses: What the Experts Say
What actually happens is that Medicare covers just one pair of glasses or contacts after the second surgery, says Tracy Holt, MHR, COPC, transformational services account manager for Eye Care Leaders.
“It has been my experience that Medicare will only pay for one pair of glasses even though it says ‘after each cataract surgery.’” There’s a lot of ambiguity in the CMS guidance and, generally, patients end up needing that second pair of glasses, Holt adds. “I have tried to bill after each surgery for a pair of glasses for the patient and one pair was denied and one pair was paid. So typically, when the patient is finished with the second eye, during post-op, the doctor does a refraction and we complete the order for the glasses.”
The Medicare post-cataract eyeglasses benefit covers standard frames, prescription lenses, slab-off, prism, balance lenses, wide segment, and UV filtration, says Mary Pat Johnson, COMT, CPC, COE, CPMA, a presenter at Vision Expo East. Items not covered include low vision aids, scratch coating, and edge treatments. Medicare will rarely cover tint, oversize lenses, A/R coating, polycarbonate, or high index, she adds. So does Medicare also pay for the eye exam? No. Medicare does not cover routine eye exams/refractions for eyeglasses or contact lenses.
To Sell Add-ons, Use a Medicare ABN Form
What should you do if Medicare’s stripped-down post-cataract eyeglasses coverage isn’t all that attractive to a post-surgery patient? Or if it doesn’t adequately meet that patient’s vision needs? You have an opportunity to sell additional features not covered by the Medicare benefit. You can collect directly from the patient for these items. To do that compliantly and to collect your full reimbursement, you’ll need to provide and have the patient sign an advance beneficiary notice of non-coverage (ABN) before you deliver the post-cataract eyewear.
The ABN is CMS-required form, mandated by HIPAA. It provides notice to the patient that Medicare will probably deny coverage for an item or items. Generally, an ABN should describe products and/or services likely to be denied (like post-cataract glasses and refractions) and document why an item isn’t covered. Additionally, it should detail what the patient will need to pay. When it comes to being a durable medical equipment supplier (DME) “what doctor’s offices don’t realize is that if they do not have that ABN, legally, they cannot bill the patient. And so that’s a huge issue,” says Holt.
ABNs are not a front desk thing:
The ABN is a form that requires special consultation and should be treated as such. “The ABN should not be filled out at the front desk, which is where it’s usually done,” says Holt. “ABNs should be completed either in the exam lane or in the optical with the optician. That is who has the knowledge of what’s going on with that patient for that charge,” she advises.
Don’t rush through ABN completion:
Prepare to set aside time to talk with the patient about this form and its contents. As a supplier, you’re responsible for carefully reviewing what insurance won’t pay with the patient ahead of time. You must also answer all of the patient’s questions, before the patient signs, says CMS in its ABN form instructions. Most practices place a high premium on efficiency, but when it comes to the ABN, this can have unintended consequences. Providers try to breeze through it as fast as possible, not taking enough time to answer patient’s questions, says Holt.
You must deliver the form far enough in advance so that the beneficiary has time “to consider the options and make an informed choice,” according to CMS. The advance preparation part of the ABN process is the key challenge for most practices, says Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, vice president of strategic development for Eye Care Leaders. The beneficiary needs to have adequate notice prior to performing the service and must know Medicare may not cover it. The beneficiary must also be informed the reason why and how much it will cost, she continues.
Resource: For more on ABNs and CMS-R-131 form, visit https://www.cms.gov/medicare/medicare-general-information/bni/abn.html.