Medicare--please help!

[Mr_Mitchell]

There is mass confusion in my office regarding medicare, and a call to healthnow/dmerc simply got me an answering machine.
My question is, if medicare pays let's say 50 bucks (I think it's 52.44) towards a frame, would a patient pay 9 dollars for a 59 dollar frame and we bill medicare the rest? If so, what's the point of the "deluxe" frame category (any frame over $125)? If the patient pays the difference, I don't see how it matters if the frame is "deluxe" or not, and yet there's a code for this category.
My eternal gratitude to anyone who can answer this or point me to the answers!

[Spexvet]

The v2025 (I think) code is the difference between the retail price of the frame and Medicare's allowable. In your example, the deluxe frame amount would be $125 - $50 = $75.00. Remember to collect the 20% of the Medicare allowable that Medicare does not pay $50 * 20% = $10.00.

[Excel-Lentes]

This question would best be answered by a Medicare Provider Relations Specialist (Good luck getting in touch with one!). I have actually come to work early to try to contact one by phone.

Example: Frame Cost $130.00

V2020 Basic Frame $50.00
V2025 Deluxe Frame $80.00 (pt. pays)

Reimbursement is actually 80% so the patient must also pay the 20% of the frame allowance unless the patient has a supplemental plan.

Sorry if I confused things further. I don't see many Medicare patients and I actually look this stuff up before sending in a claim.

Good luck:hammer:

[AutumN]

Mr. Mitchell

This is my first post to the board, but I've been watching your posts and thought I could help. I also manage an MD dispensary and know what you're going through. As far as Medicare goes, there are many specifics to keep in mind. As was stated above the frame is broken down to the basic on the V2020 and the additional on the V2025. You also have to do the same thing with a progressive lens. The basic fee on the V22--or V23-- and the additional add-on for the progressive on the V2781. Also don't forget the modifiers! If a patient gets transitions say, which would be V2744, and you don't include the EYGA modifiers, then Medicare not only denies as not necessary, but the pt's EOB will say that they are not responsible for payment. If you par, then you can not collect payment, or if you already have, and the patient complains to Medicare, they will make you refund to the patient! The EYGA means that the item is a patient preference and that you have a signed ABN (Advance Beneficiary Notice), that means that the patient is aware that they are responsible for the charge and their EOB will state that. An ABN has to be on file for any add-ons not covered by Medicare with the exception of the deluxe frame and scratch coating.
If you go online to your carriers website, you will find downloads with all the modifier lists, a copy of an ABN, and their billing guidelines on the different codes.
Hope I helped.

[Mr_Mitchell]

Thank you thank you thank you!!! You've really helped me understand this better.

[harry888]

Don't forget the waiver a patient must sign stating they got a "deluxe" frame with the v2025 overage. Same with deluxe lenses.

If client calls Medicare to complain that they paid for their "free" glasses and there is no waiver signed, you MUST refund them what they paid. Worked at an office where that happened.

Form is basic, email me privately with your fax number and I'll Fax it to you.

Harry

[cocoisland58]

We don't bill medicare but I do know this from other insurance billing. If the patient pays the difference on a frame over coverage and you bill the covered code 2020 instead of the deluxe code 2025, when the patient recieves the statement from the insurance it will say that he should not have paid any overage on the frame. This will cause the patient to come back and ask why he paid so much for the frame when his insurance clearly states he should owe nothing. I have learned to check certain claims before they get sent out because of this error in billing. It can be corrected but the patient still thinks you tried to screw him.

[FOREYES21]

I'm not sure how to bill a balance lens. There's a code for a balance but the reimbursement amount is less than that for a regular SV lens. If the patient is getting a FT bifocal I would be getting considerably less for a balance than I would if I just billed for a bifocal. Can I still get paid for poly even if I don't specify that one lens is a balance?

[AutumN]

Yes, unfortunately the reimbursement for the balance lens is low, but you can get paid for the poly. You have to use a KX modifier, so it would be
V2784KXRTLT, indicating that it is a doctor ordered item. You have to have documentation that it is DR ordered by either having it on the rx or if it is from your own office, then documentation of the need in the chart. You can also do this with a slab off.

[AutumN]

If you par with medicare, I would definetly bill as a balance lens, since your records are eligible for audit. However, you can still bill poly even without a balance lens. You would just need to make sure there is medical need, like an amblyopic situation.

[FOREYES21]

Thanks Autumn. Just curious...how many of you do your own Medicare billing? I was looking into sending my claims to a billing service but the MDs who own the practice think I should be able to do it myself, in addition to the million other things I am doing. We probably have about 15-25 claims/month.

[AutumN]

We have 3 MDs in the practice, and we do our billing electronically. Though it goes through a clearing house via our software support company who, I believe, routes it to all the different carriers. So basically once the charge is entered, we just send the claims every couple of days.

On a different note, does anyone bill for 2 pair of glasses when the pt is having both eyes done close together? Say a pt has surgery do you give them an Rx after, when they are scheduled for the second within a couple of weeks, so they can utilize the benefit for 2pr or do you wait until after the second eye is done and Rx for only one? The previous Dr I worked for had them get the first prior to the second surgery that was a week away. I thought it would be a flag to Medicare, but his reasoning was that it was a benefit they were entitled to so we should. The practice I'm at now waits until after the second surgery. In one way it seems like taking advantage of the system, but on the other hand the pt is entitled and it gives them an opportunity to have a spare pair on hand.