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Thread: Fresnel Prism and Medicare

  1. #1
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    Fresnel Prism and Medicare

    Clearly there are times where Fresnel lenses are handy. Today one walked in that I believe is medically necessary. Medicare has priced out the HCPC code (v2718).. any idea if they will ever pay? Not sure where to look for the appropriate (in the eyes of Medicare/DMERC) & corresponding ICD-9 code. I'd assume it's one of the strabismus codes, but Medicare has to have a list somewhere...

    Thanks for your insights!

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    Jeeze Louise:
    This is an item that cost you less than $20.00 you should be getting the run around on over a years worth of prosthetic eye (about 300) at $1400.0 a pop.
    Sometimes one will actually loose a few nickel and dimes.

    Chip

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    Medicare does not cover fresnells unless it's done in conjunction with eyeglasses following cataract surgery. The only dx they will cover eyeglasses with is V43.1, pseudophakia. Also, don't forget to have the patient sign an ABN saying they are aware they're responsible for pmt.

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    Quote Originally Posted by AutumN View Post
    Medicare does not cover fresnells unless it's done in conjunction with eyeglasses following cataract surgery. The only dx they will cover eyeglasses with is V43.1, pseudophakia. Also, don't forget to have the patient sign an ABN saying they are aware they're responsible for pmt.
    Just curious - I've never seen medicare pay for slab off or prescribed prism on post op glasses - What's your magic formula?
    "I just love the smell of Optidirt in the morning.

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    Medicare will cover when you use the KX modifier indicating it was Dr ordered. There has to be supporting documentation in the chart if the rx comes from the same place, or it has to be on the rx if it comes from outside. We don't have a problem getting coverage. We never bill for a fresnell however, even after surgery because if they pay for the fresnell, that constitutes use of their full benefit. If a patient decides to have the prism ground in, then the benefit will already be used and they lose out.

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    Quote Originally Posted by chip anderson View Post
    Jeeze Louise:
    This is an item that cost you less than $20.00 you should be getting the run around on over a years worth of prosthetic eye (about 300) at $1400.0 a pop.
    Sometimes one will actually loose a few nickel and dimes.

    Chip
    (edited to be softer)
    I resent the fact that many believe everyone is out for a nickel. This is a coding question and not "who is gonna pay me" question. I'm generally well-compensated for my time. The guy sees double from a medical condition and I happen to feel like this falls under DMERC. I know you better than to misinterpret your post as a toll...
    Last edited by allanon; 05-18-2007 at 12:23 PM.

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    Medicare will not pay unless it's after cataract surgery, however if it is, then use the kx modifier and they will pay(most of the time). Also, as above, you have to use the v43.1 code. Good luck.

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    Fresnel Medicare payment

    You mentioned you did not have any trouble getting paid for Fresnel Prism using KX modifier, but then you said you did not bill medicare. Do you have a DME liscense?If you use the KX modifier what V code do you use? Help











    Quote Originally Posted by AutumN View Post
    Medicare will cover when you use the KX modifier indicating it was Dr ordered. There has to be supporting documentation in the chart if the rx comes from the same place, or it has to be on the rx if it comes from outside. We don't have a problem getting coverage. We never bill for a fresnell however, even after surgery because if they pay for the fresnell, that constitutes use of their full benefit. If a patient decides to have the prism ground in, then the benefit will already be used and they lose out.

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    Rochester Optical WFruit's Avatar
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    I can't even make a snide comment about this being a 3 year old thread, since with medicare, it could still be ongoing......
    There are rules. Knowing those are easy. There are exceptions to the rules. Knowing those are easy. Knowing when to use them is slightly less easy. There are exceptions to the exceptions. Knowing those is a little more tricky, and know when to use those is even more so. Our industry is FULL of all of the above.

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