Transition Definition Needed

[Tammy]

I'm in need of a technical definition of tranition lenses for DMERC (Adminastar Federal), Due to the fact that their allowable fee is only $13.49 per lens, DMERC has stated that I must bill for Transitions under the code V2744 (photochromic lenses) I don't know about anyone else but that amount does not even cover cost, and they stated that I must write off the difference, and only charge the patient $26.98/pr, HELLO! So if anyone is out there that can give me a GREAT DEFINITION to include in an attachment I would greatly appreciate it.

Thank you for all your help in advance. And yes I do use a GA modifier.

Tammy

[Jim Schafer]

Tammy,
This is the best summary I could come up with.

Transitions®Lenses are available in four photochromic colors, six lens materials, seven refractive indices, eight lens types and over sixty premium branded designs that best meet the requirements for every patients Rx.

regards,
Jim

[Jo]

Tammy,

I thought the government covered enhancements if the Rx lists them as medically necessary - light sensitivity, for example. If you have a patient that requires a photochromic lens for eye-health reasons, I am surprised that the government doesn't cover at least partial cost of Transitions. Transitions that aren't high index or polycarbonate are a reasonable cost and a safer lens than glass.

Jim,

Is there anywhere online to find a spec comparison of Transitions to PGX? I am thinking Tammy could include a note about ANSI impact resistance in regards to Transitions.

[Tammy]

Jo,

The Government has specifically stated that items are not covered unless doctor ordered, and you better have documentation in the patient chart to support it. The only extra item I have ever been paid for is UV and that is only when the patient is aphakic. Adminastar does not pay for UV for a pseudophakic due to the fact that UV is in the IOL. This was issued in the Medical Policy in December of 1997, rev 12.

In all my offices the opticians use a GA waiver form, that the patient signs stating that they know that Medicare will not cover the cost for any specialty items (even though I must bill everything that they purchased, covered or not, its the law), that is why I use a GA modifier on any item that is not standard ex. progressives, transitions, scratch coat, uv, AR, tint (of any kind), and a deluxe frame. The patient receives an EOB stating that they are responsible for the allowable amount. That is the reason for my original request.

I think that the spec comparison would be great, to include with documentation. Jim thank you for your definition, and if anyone would be willing to direct me to the above I would greatly appreciate it.

Thank you for all your help,

Tammy (your friend in the billing department)

[sandeepgoodbole]

Jim Schafer said:
Tammy,
This is the best summary I could come up with.

Transitions®Lenses are available in four photochromic colors, six lens materials, seven refractive indices, eight lens types and over sixty premium branded designs that best meet the requirements for every patients Rx.

regards,
Jim

I never knew about this Galaxy of the varities of Tranzitions.
Please elaborate on types of all of those .:drop:
In my college days, they have tought me that Silver Hallieds are the key compounds behind Photochromic properties.
Is that applicable to Tranzitions too?

[Jim Schafer]

Hello Sandeepgoodbole,
Inorganic systems as Silver Halide technology made its mark in glass.
Plastic lens substrate is not compatible with Inorganic systems.
Early plastic photochromic lens technology used Organic Spiro-Oxazine chemistry. Since the mid 1990's the technology shifted to Napthopyrans, another organic family of photochromics. PPG Industries (the parent company of Transitions Optical) has over 100 patents for over 1,000 cataloged organic photochromics and the technologies to manufacture photochromic products.

You may not have known that Transitions Optical has a sales office in Bangalore India. It has been there for at least 4 years.
TRANSITIONS OPTICAL INC
c/o DBS Corporate Club
Room 203
26 Cunningham Road
Bangalore 56052 India
Tel: 91-80-267272
Fax : 91-8-2251133

Our Asian HQ is in Singapore.
TRANSITIONS OPTICAL INC
16 Collyer Quay #29-02
Hitachi Tower
Singapore 049318
Tel: 65-536 6878
Fax : 65-536 6879
Email: contactus@transitions.com.sg

As of today Transitions 1.50 Next Generation has not launched in your country.
I am sure if you email the Singapore office, someone will get back to you with the availibility information in India.
best regards,
Jim

[Bev Heishman]

We have approximately one patient per year that requires lenses that change with the light. We make accomodations when necessary for this. (write off) Those who are not medically necessary we let the patient know at time of order that this is not covered by DMERC and will most likely be their responsibility when signing the waiver so there are no surprises.

We also have similar situations involving price with wider segs and PGX, Progressives, PBX simply because the cost exceeds the allowances. This is the patients preference not ours.

[Pete Hanlin]

Hi Tammy,

We have the same problem with BCBS when we use Crizal AR Coating (unfortunately, V2750 is actually covered by some BCBS plans, but for only $19!). My stab at a definition would be:

"As an add-on, Transitions allows the ophthalmic device to adjust to changes in lighting conditions. The product is activated by ultraviolet light, and filters >99% if UVA and UVB light."

I would think you should also be able to bill for a UV coating when using Transitions (V2755, I think).

You could also try the path we have chosen (i.e., we bill the Crizal as V2799, which is unspecified and is always transferred over to the patient by the insurer).

Don't know if this was any help- you ARE the insurance guru, but good luck!