Optometry Coding: Update Your Knowledge and Get the Reimbursements

Optometrists describe durable medical equipment (DME) coding and billing as one of the most complex duties they perform. For you, optometry coding for refractive lenses can make it even more complex - with the multitude of options available to patients combined with Medicare’s strict coverage guidelines. You have to understand what Medicare pays for.

Medicare only pays for refractive lenses for patients who lack the organic lens of the eye due to surgical removal. Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens.

Most DME Medicare Administrative Contractors (DME MACs) specify that your claim for refractive lenses must be linked to one of these ICD-9 codes to prove medical necessity:

• 379.31 - Aphakia
• 743.35 - Congenital Aphakia
• V43.1 - Organ or tissue replaced by other means (lens)

The key to DME MAC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code. The prescribing physician must specifically order the special lens; it cannot be simply the patient’s preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity of the item you’re claiming.

If the prescribing physician did not specifically order an item, but the patient wants it anyway, append optometry coding modifier to patient-preference items. Append modifier EY to V2744, V2745, V2750, V2780 and V2784 if the patient selects them without a specific order from the prescribing physician. You may also need to append modifiers LT (Left side) and RT (Right side). If you’re providing the same lens on both sides, bill both on the same line of the claim form, append both LT and RT, and claim two units of service.

Optometry coding gets tricky if you are not sure of the modifiers, so make it a practice to get the updates on time to get home all the reimbursement you deserve.