DMERC glasses rules

I'm new to billing DMERC for glasses after cataract surgery (just received billing number) and I had a couple questions. I'd really appreciate if someone could take some time to give me some answers. I'm struggling to get solid answers from the DMERC program in my area (Missouri)

A) What kind of 'Basic' Frames do I need to carry? Is there a certain number that I must carry to fulfill their requirements?
B) If the patient chooses a deluxe frame, do I then, at the time of their fitting, charge them the difference between the deluxe and basic frame and, also, the 20% of the allowed on the basic frame. Do I then have them sign an ABN (Advance Beneficiary Notice) for the deluxe frames.
C) Do I need to keep a record of the referring ophthalmologist that did the surgery and a copy of the RX in the patient's record?
D) Is there any Signature on file requirement? Do I need to get permission to bill that way?
E) When I code for the lenses ie...V2203, etc. , do I fill in my normal and customary fees in the boxes or the allowable amounts that Medicare covers.
Is it logistically simpler to just wait to bill the patient until after I know what Medicare is or is going to pay or allow.

Again, thank you for your answers!!!

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Originally Posted by Dr. B

A) What kind of 'Basic' Frames do I need to carry? Is there a certain number that I must carry to fulfill their requirements?

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I've never seen any minimum requirement for "basic" frames. The frame just has to priced at $50.28 or lower (New Jersey allowable). You need the kind that will allow you to make a profit at that price.

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Originally Posted by Dr. B

B) If the patient chooses a deluxe frame, do I then, at the time of their fitting, charge them the difference between the deluxe and basic frame and, also, the 20% of the allowed on the basic frame. Do I then have them sign an ABN (Advance Beneficiary Notice) for the deluxe frames.

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Yes, to all of that. If a frame is $100, I collect $100 - $50.28 = $49.72 plus $50.28 * 20% = $10.06 for a total of $59.78, and recieve $40.22 from DMERC. Just remember to bill for V2020 $50.28, because they'll pay 80% of that amount.

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Originally Posted by Dr. B

C) Do I need to keep a record of the referring ophthalmologist that did the surgery and a copy of the RX in the patient's record?

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If you are audited, you must produce a Certificate of Medical Necessity. I don't know how long you must keep that. In New Jersey, we must keep Rx records for six years.

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Originally Posted by Dr. B

D) Is there any Signature on file requirement? Do I need to get permission to bill that way?

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My software prints the information onto the HCFA-1500, including the doctor's "signature" and patient's signature on file, and I get paid.

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Originally Posted by Dr. B

E) When I code for the lenses ie...V2203, etc. , do I fill in my normal and customary fees in the boxes or the allowable amounts that Medicare covers.

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The way I understand it, if you put in your regular price, and it is higher than the allowable, they'll instruct you to "write off" the difference. I've set up my pricing so that I don't have to do that (allowable for a pair of V2203 ft28s is $110.60, my price $110.00).

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Originally Posted by Dr. B

Is it logistically simpler to just wait to bill the patient until after I know what Medicare is or is going to pay or allow.

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I have a spreadsheet - I plug in the codes and amounts, and it shows the amount that DMERC will actually pay, the amount to bill, and the OOP from the patient. I ALWAYS COLLECT THEIR AMOUNT BY THE TIME THEY PICK UP THEIR GLASSES. You can't submit the claim until they are in possession of their glasses. And remember, if you enter anything above zero in "amount paid" (box 29), the check will be sent to the patient.

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Originally Posted by Dr. B

Again, thank you for your answers!!!

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Hope they help.

When billing for a frame above basic you must bill v2020 for the basic charge and v2025 for the deluxe charge. Otherwise you may not charge the patient the additonal amount for the deluxe frame.

OR..

You could require that the patient pay in full up front. Do not accept assignment of benefits. File the paperwork and let Medicare reimburse the patient.

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Originally Posted by Judy Canty

OR..

You could require that the patient pay in full up front. Do not accept assignment of benefits. File the paperwork and let Medicare reimburse the patient.

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You can only do that if you are a non-participating provider and you can only charge 115% of the allowed amount.

Also Make sure you get the ABN signed for the deluxe frame code. Patient can claim you never told them and medicare will not allow you to collect the extra.
Cheers

You need to bill the retail price of the lenses, frame, etc. You need to use the modifiers to show what the patient will owe and what is medically necesary. If you don't use those modifiers, the patient isn't responsible for the overages. You need to check with your state though as it varies.

Do you guys get a lot of those patients?

Are you asking me DRK?


If so, yes, we do.

Are they mostly from a particular OMD office?

Yea, from a couple of regular offices that don't do refractions and/or sell glasses.

The first M/C claim I personally filed about 12 years ago, a man got a frame for $150. I charged him the difference between the deluxe and basic frame. I billed M/C for a V2020 frame for $150, The EOB came back stating that the patient was not responsible for the difference, because a basic frame is completely covered. He came running in for his refund. That's never happened again.

You need to bill both if they get a frame over the basic frame and when billing the deluxe frame, you have to use the expected denial modifier or else it will state they're not responsible. At least that's how we do it here.

If they go above the frame allowance or want deluxe lenses, you MUST have them sign a waiver stating they chose deluxe frames and/or lenses.

Then bill the V2025 for deluxe frames, then the codes for the deluxe lens add ons (progressive, A/r, scratch coat, thin lens etc). This is so they can be denied.

You must accept the assignment for the SV or Bi or Tri lenses, you can only charge for the add ons. The rules on light tints keep changing, sometimes paid, sometimes denied. Photochromatic/transitions NOT covered.

Again, you MUST have them sign the waiver. Email me privately with your FAX and I will send mine.

Harry