rSubmit a claim for with the CPT®surgery code 66984and co-management modifier -54(e.g., 66984-54) rSubmit a claim for your portion of the post-operative care by submitting a second line item entry on the form for the same surgery procedure code with the modifier -55.
Does Medicare cover post-cataract glasses after cataract surgery?
Given this directive, it would appear a patient who has had cataract surgery on one eye and is waiting to have the second eye done could qualify for post-cataract eyewear after the first surgery and an additional pair of Medicare-covered glasses after the second.
Is coding and billing for post-op cataract care difficult?
Comanagement and billing for post-op cataract care—especially for patients who receive presbyopia-correcting IOLs—can be problematic. Coding and billing for services rendered to postsurgical cataract patients continues to raise issues in many optometric offices.
How do I receive reimbursement for post-cataract eye care?
To do that compliantly and to collect your full reimbursement, you’ll need to provide and have the patient sign an advance beneficiary notice of non-coverage (ABN) before you deliver the post-cataract eyewear. The ABN is CMS-required form, mandated by HIPAA.
Should you establish a set price for cataract post-op care?
Establish a set price for cataract post-operative care. Why? Because Medicare and the likes of other insurance companies consider post-op work to be a maximum of 90 days and pay a certain amount for this procedure intended to cover you for ALL visits with this patient in the 90 days following the actual surgery.
How do you bill for cataract surgery post op care?
The date of service should correspond to the date of the surgery. Use the same surgical CPT procedure code used by the surgeon, but add the -55 modifier to signify that you are rendering the postoperative care. The number of units billed can vary by carrier, so be aware of your carriers requirements.
Does Medicare pay for follow up visits after cataract surgery?
For example, medically necessary “diagnostic tests” are outside of the package and paid separately. However, a final refraction following cataract surgery is not covered by virtue of the Medicare law, and not bundled with the global surgery package. It may be billed separately to the beneficiary.
How do you bill for post op care only?
In those cases where the postoperative care is "split" between physicians, the billing for the postoperative care should be reported as follows: Report the date of service using the date of the surgical procedure. Report the procedure code for the surgical procedure, followed by modifier 55.
What is the 55 modifier used for?
postoperativeModifier 55 is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier.
How do I bill Medicare for post cataracts glasses 2021?
Medicare will pay for one pair of post-cataract surgery glasses per lifetime per eye after cataract surgery....Payable diagnosis codes include:Z96. 1 (pseudophakia)H27. 01, H27. 02, H27. 03 (aphakia)Q12. 3 (congenital aphakia)
Does Medicare pay for laser cataract surgery in 2020?
Medicare coverage and payment for cataract surgery is the same irrespective of whether the surgery is performed using conventional surgical techniques or a bladeless, computer controlled laser. Under either method, Medicare will cover and pay for the cataract removal and insertion of a conventional intraocular lens.
Can you bill for a post op visit?
Post-operative visits should be reported with CPT code 99024 when the visit is furnished on the same day as an unrelated E/M service (billed with modifier 24).
What is modifier 59 used for?
Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
What is the 32 modifier used for?
When to use Modifier 32. Modifier -32 indicates a service that is required by a third-party entity, Worker's Compensation, or some other official body. Modifier 32 is no used to report a second opinion request by a patient, a family member or another physician. This modifier is used only when a service is mandated.
What does modifier 80 stand for?
assistant at surgery byCPT Modifier 80 represents assistant at surgery by another physician. This assistant at surgery is providing full assistance to the primary surgeon. This modifier is not intended for use by non-physicians assisting at surgery (e.g. Nurse Practitioners or Physician Assistants).
When do you use modifier 66?
Definitions. Current Procedural Terminology (CPT®) modifier 66 describes when three or more surgeons of same or different specialties work together as primary surgeons performing distinct part(s) of a surgical procedure.
What is modifier 79 used for?
Modifier 79 is used to indicate that the service is an unrelated procedure that was performed by the same physician during a post-operative period. Modifier 79 is a pricing modifier and should be reported in the first position. A new post-operative period begins when the unrelated procedure is billed.
How many cataract surgeries are performed annually?
Every year, more than 3.8 million cataract surgeries are performed by ophthalmologists and postoperative care is often co-managed with referring optometrists. More than 25 million Americans have cataracts, reports the Prevent Blindness “ The Future of Vision ” study.
Why aren't the correct modifiers appended on the second postoperative claim?
Since the cataract post-op care was performed within the global period of the first postoperative claim, the office billers were not appending the correct modifier on the second postoperative claim to ensure both claims were paid correctly.
Can you co-manage cataract surgery?
When you co-manage a cataract surgical procedure that was performed by a surgeon, be sure to use the correct modifier. Keep in mind that if the surgeon has not filed their claim, or if they filed without using the correct modifier indicating surgical care only, your co-management claim will be denied.
Does Fast Pay Health process Medicare claims?
Fast Pay Health optometric billing consultants process hundreds of Medicare claims every week. Let’s look at the challenge, solution, and outcome that Fast Pay Health put into action for a two-doctor, one-location Texas-based optometry practice who was struggling with denied Medicare claims for cataract post-op co-management services.
When did Medicare start paying for surgical procedures?
Medicare established global surgical packages (PDF, 645 KB) in 1992 which include all the necessary services normally furnished by a surgeon before, during and after a procedure. In these instances, Medicare payment for a surgical procedure includes the preoperative, intraoperative and postoperative services routinely performed by the surgeon.
Why do surgeons need to provide additional medical services during the postoperative period?
All additional medical or surgical services required of the surgeon during the postoperative period because of complications which do not require additional trips to the operating room
What is CPT modifier 54?
CPT Modifier 54 — surgical care only (submit this modifier when one physician performs a surgical procedure and another provides preoperative and/or postoperative management)
What is the role of an ophthalmologist?
When a patient requires ocular surgery, the operating ophthalmologist (surgeon) has the ultimate responsibility for the preoperative assessment, surgical procedure and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the postoperative care, contingent on medical stability of the patient. However, when medically appropriate, the operating ophthalmologist’s postoperative care responsibilities may be delegated to another qualified healthcare practitioner as part of a co-management arrangement or as a transfer of care, under appropriate circumstances.
What is the EMC for postoperative care?
The date on which postoperative care was assumed by the non-surgeon optometrist should be provided in Item 19 (or EMC equivalent) of the CMS-1500 claim form and the number of postoperative days the patient was under the care of the optometrist
What is the scope of practice of an optometrist?
Optometrists are licensed by the state in which they practice, and their scope of optometric practice is determined by a state’s designated governing body for optometry, which varies from one state to another. In addition to adhering to state law scope of practice requirements, services provided by optometrists must be medically reasonable ...
When is the availability of an ophthalmologist an issue?
In cases in which the surgeon-ophthalmologist’s availability is an issue, or when there is a change in the postoperative course necessitating a different course of treatment
What to do if you haven't been billed for post op surgery?
Coordinate with the surgeon's billing staff-make sure that you verify what was billed to Medicare when they originally billed for the surgery. IF THEY HAVEN'T BILLED THE SURGERY YET THEN DON'T BILL FOR THE POST-OP WORK, YOU WILL NOT GET PAID!
How long does post op work last?
Because Medicare and the likes of other insurance companies consider post-op work to be a maximum of 90 days and pay a certain amount for this procedure intended to cover you for ALL visits with this patient in the 90 days following the actual surgery.
When do you have to write in the dates that you saw the patient?
You will need to write in the dates that you saw patient-This means that when you manipulate the claim lines you will have to write a) the date you saw the patient and b) the date, 90 days from the start date, the post-op care will terminate. Also, you need to write 90 days after the dates.
Is it hard to bill for cataract surgery?
Billing for Cataract Post-Operative care should not be hard. It should be as easy for billing for an eye exam. With opticXpress at your side, billing for these services IS EASY! Watch this 59 second video to see just how easy it can be. Then...
Can you bill a catarac post operation?
Cataract Post-Operative Billing Can Be Easy!
Is the date of service the date of the surgery?
The date of service IS NOT THE DATE YOU SEE THE PATIENT, IT IS THE SURGERY DATE!
Do opthamological centers have referral sheets?
This sheet will list the procedure code used to bill medicare by that office for the original surgery as well as an modifiers that may have been used and the ORIGINAL surgery date. IF THE PATIENT DOESN'T HAVE THIS SHEET AND YOU CAN'T GET IT FROM THE SURGEON'S OFFICE, DON'T PERFORM THE EXAM UNTIL YOU DO.
When did CMS clarify payment rules for presbyopia correcting intraocular lenses?
In May 2005, CMS clarified payment rules for those patients who choose presbyopia-correcting intraocular lenses. This allowed providers to balance bill the patient for non-covered care related to the presbyopic portion of the pre- and postoperative care provided. Patients who choose these lenses are responsible for the additional expenses for services that exceed the charges for conventional IOLs.
How long does cataract surgery last?
The Centers for Medicare and Medicaid Services (CMS) has determined that the postoperative global period following cataract surgery is 90 days. Also, the CMS-approved reimbursement for the postoperative portion of the cataract surgery is 20%.
What does the -55 modifier mean?
Use the same surgical CPT procedure code used by the surgeon, but add the -55 modifier to signify that you are rendering the postoperative care.
How long after transfer of care can you bill?
You should bill for all of the days following the transfer of care, but you cannot submit the claim until youve evaluated the patient at least once. The ophthalmic surgeon must be listed as the referring physician. The diagnostic code you use needs to be identical to that used by the surgeon.
Do Medicare Part B insurance companies follow the same guidelines?
Take note: These guidelines refer only to Medicare Part B. Although many insurance carriers follow the same guidelines, some do not. Make certain you contact your local carriers prior to submitting claims to ensure that youre compliant with their guidelines and policies.
What should you do if Medicare’s stripped-down post cataract eyeglasses coverage isn’t all?
To do that compliantly and to collect your full reimbursement, you’ll need to provide and have the patient sign an advance beneficiary notice of non-coverage (ABN) before you deliver the post-cataract eyewear.
Does Medicare cover glasses after second eye surgery?
What actually happens is that Medicare covers just one pair of glasses or contacts after the second surgery, says Tracy Holt, MHR, COPC, transformational services account manager for Eye Care Leaders.
Does Medicare cover IOL?
Whether the patient has an Intraocular Cataract Lens (IOL) implant determines the extent of Medicare glasses coverage. CMS states that “One pair of conventional eyeglasses or conventional contact lenses furnished after each cataract surgery with insertion of an IOL is covered,” according to the Medicare Benefit Policy Manual, Ch. 15. “Covered Medical and Other Health Services,”§ 120.B.3.
Can you collect from a patient for cataract eyewear?
You can collect directly from the patient for these items. To do that compliantly and to collect your full reimbursement, you’ll need to provide and have the patient sign an advance beneficiary notice of non-coverage (ABN) before you deliver the post-cataract eyewear. The ABN is CMS-required form, mandated by HIPAA.
Does Medicare cover cataract surgery?
Medicare Coverage of Post-Cataract Eyeglasses, Explained. You may already know this, but it’s worth emphasizing: Medicare does not cover refractions, eyeglasses, or contact lenses for beneficiaries. The exception is for post-cataract surgery or in cases when surgery results in the removal of the eye’s natural lens.
Does Medicare pay for cataract glasses?
The Medicare post-cataract eyeglasses benefit covers standard frames, prescription lenses, slab-off, prism, balance lenses, wide segment, and UV filtration, says Mary Pat Johnson, COMT, CPC, COE, CPMA, a presenter at Vision Expo East. Items not covered include low vision aids, scratch coating, and edge treatments. Medicare will rarely cover tint, oversize lenses, A/R coating, polycarbonate, or high index, she adds. So does Medicare also pay for the eye exam? No. Medicare does not cover routine eye exams/refractions for eyeglasses or contact lenses.
What determines the operative eye is sufficiently stable for transfer of care or co-management?
The operating ophthalmologist determines that the operative eye is sufficiently stable for transfer of care or co-management.
What is co-management in Medicare?
Federal Medicare policy concerning co-management has been adapted and interpreted by states and carriers with variations in details and restrictions. The operating ophthalmologist has the ultimate responsibility for the preoperative assessment and postoperative care of the patient, beginning with the determination of the need for surgery and ending with completion of the postoperative care contingent on medical stability of the patient. Economic considerations, such as inducement for surgical referrals or coercion by the referring practitioner, should never influence the decision to co-manage, or the timing of the transfer of a patient’s care following surgery. Any such quid pro quo arrangement is unethical and, in many jurisdictions, illegal. The Office of Inspector General of the Department of Health and Human Services has expressed concern about co-management based on economic considerations rather than clinical appropriateness and has refused to provide safe harbor protections for such arrangements, preferring to review cases on an individual basis. 1
What is co-management in ophthalmology?
Co-management is a relationship between an operating ophthalmologist and a non-operating practitioner for shared responsibility in the postoperative care when the patient consents in writing to multiple providers, the services being performed are within the providers' respective scope of practice and there is written agreement between the providers to share patient care.
What is an operating ophthalmologist?
The operating ophthalmologist or an appropriately trained ophthalmologist is available upon request from either the patient or non-operating practitioner to provide medically necessary care related to the surgical procedure directly or indirectly to the patient.
What is transfer of care?
Transfer of care or co-management is documented in the medical record as required by carrier policy. All relevant clinical information is exchanged between the operating ophthalmologist and the non-operating practitioner.
What is the Office of Inspector General of the Department of Health and Human Services concerned about?
The Office of Inspector General of the Department of Health and Human Services has expressed concern about co-management based on economic considerations rather than clinical appropriateness and has refused to provide safe harbor protections for such arrangements, preferring to review cases on an individual basis. 1.
Is Medicare fee structure appropriate?
For services that are not covered by Medicare or Medicaid, other fee structures may be appropriate, though they should also be commensurate with the services provided, disclosed and consented to in writing by the patient, and otherwise comply with all applicable federal and state laws and regulations.
When do providers report post operative care?
Note: Providers must report the date when post-operative care is assumed from another provider including the date post-operative care began and ended along with the number of post-operative care days provided in the narrative field on electronic claims, or item 19 on the CMS 1500 claim form. This will facilitate processing of the claim and reduce unnecessary rejections.
What does it mean when a physician demands to manage the postoperative care?
A physician demands to manage the postoperative care and indicates that he/she will withhold making referrals to surgeons who would not agree to split global surgery payments.
Why do surgeons split care?
Reasons for splitting care. The operating surgeon is unavailable after surgery and the patient's postoperative care has to be managed by another physician. The patient is unable to travel the distance to the surgeon's office for postoperative care visits.
What modifier is used for post operative care?
In the case where the surgeon also cares for the patient for some period following discharge, the surgeon should bill the surgery with a 55 modifier and indicate the portion of the post-operative care provided in addition to the surgery with a 54 modifier (to indicate the intra-operative service).
What is transfer of care?
The transfer of care is used as an incentive for obtaining referrals from providers to receive postoperative care reimbursement.
When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits?
When different physicians in a group practice participate in the care of the patient and all the physicians reassign benefits to the group, the group bills for the entire global package. The physician who performs the surgery is shown as the performing physician. No modifier is necessary.
When to use modifier 54 and 55?
Specific billing guidelines must be followed when the surgical procedure and post-operative care is split between different physicians. Modifiers 54 and 55 are used to indicate two different physicians are rendering the surgical care and post-operative management services. Where physicians agree on transfer of care during a 10-day or 90-day global period, the following modifiers are used:
What is ASCRS in ophthalmology?
This position paper, authored by The American Society of Cataract and Refractive Surgery (ASCRS) offers guidelines on co-management and transfer of care, that provides guidance to assist ophthalmologists in determining when these arrangements are appropriate.
Can an ophthalmologist be unavailable?
The operating ophthalmologist will be unavailable to provide care (e.g. travel, leave, itinerant surgery in a rural area, surgery performed in an ophthalmologist shortage area, retirement, or illness).