PROVIDER COMPLIANCE TIPS FOR LENSES

CPT Disclaimer-American Medical Association (AMA) Notice

CPT codes, descriptions and other data only are copyright 2019 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

CPT only copyright 2019 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association.

UPDATES • Replaced the earlier year’s data with 2019

• Updated Reasons for Denials

• Updated Document Requirements

INTRODUCTION This publication is meant to educate providers on coverage and proper billing for refractive lenses.

PROVIDER TYPES AFFECTED Physicians and non-physician practitioners (NPPs) who write orders for lenses

BACKGROUND According to the 2019 Medicare Fee-for-Service (FFS) Supplemental Improper Payment Data, the Medicare FFS improper payment rate for lenses was 78 percent, a projected improper payment amount of more than $30.8 million.

REASONS FOR DENIAL For the 2019 reporting period, insufficient documentation accounted for 77.5 percent of improper payments for lenses. Other error types for lenses were: Other (19.8 percent); medical necessity (0.8 percent); and no documentation (1.9 percent).

TO PREVENT DENIALS Medicare covers refractive lenses when they restore the vision normally given by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence. Medicare only covers patients for refractive lenses who don’t have a functioning natural lens. Medicare limits covered diagnoses to pseudophakia, a condition in which an artificial intraocular lens (IOL) replaces the natural lens; aphakia, a condition in which a health care professional has removed the natural lens, but there’s no IOL; and congenital aphakia. Medicare denies lenses given for other diagnoses as noncovered.

Page 1 of 3 ICN MLN909480 August 2020 Provider Compliance Tips for Lenses MLN Fact Sheet

When billing Medicare for lenses, health care professionals focus on the following policy criteria: ● Medicare covers the following lenses, or combination of lenses, when the health care professional determines the lenses medically necessary for patients who are aphakic (that is, patients who have had a cataract removed but don’t have an IOL or who have congenital absence of the lens): • Bifocal lenses in frames • Lenses in frames for far vision and lenses in frames for near vision • When a health care professional prescribes contact lens(es) for far vision (including cases of binocular and monocular aphakia), Medicare makes payment for the contact lens(es), and lens(es in frames for near vision for patients to wear at the same time as the contact lens(es), and lenses in frames for the patient to wear when the health professional removes the contacts. • For aphakic patients, Medicare covers replacement lenses when they’re medically necessary ● Medical covers anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) only when they’re medically necessary for the individual patient and the treating physician documents the medical necessity. When a health care professional gives these features as a beneficiary preference item, and the health care professional bills them with an EY modifier, Medicare will deny them as not reasonable and necessary. ● Medicare considers UV protection reasonable and necessary following cataract extraction; so, the treating physician doesn’t need to include other medical necessity justification on the order. • Medicare will deny claims for the addition of UV coating (V2755) as not reasonable and necessary for polycarbonate lenses (V2784). ● Medicare will deny tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, that health care professionals prescribe also to regular prosthetic lenses to an aphakic patient, as not reasonable and necessary. ● Medicare covers lenses made of polycarbonate or other impact-resistant materials (V2784) only for patients with functional vision in only one eye. In this situation, Medicare covers an impact-resistant material for both lenses, if Medicare covers eyeglasses. Medicare will deny claims for code V2784 that don’t meet this coverage criterion as not reasonable and necessary.

Note: Please see Local Coverage Determination (LCD): Refractive Lenses (L33793) for more coverage requirements and coding information.

CPT only copyright 2019 American Medical Association. All rights reserved.

Page 2 of 3 ICN MLN909480 August 2020 Provider Compliance Tips for Lenses MLN Fact Sheet

RESOURCES Table 1. Lenses Resources RESOURCE WEBSITE

https://www.cms.gov/files/document/2019-medi- 2019 Medicare Fee-for-Service Supplemental care-fee-service-supplemental-improper-payment-da- Improper Payment Data ta.pdf

Local Coverage Determination (LCD): Refractive https://www.cms.gov/medicare-coverage-database/ Lenses (L33793) details/lcd-details.aspx?LCDId=33793&ContrID=140 https://www.cms.gov/medicare-coverage-da- Local Coverage Article Refractive Lenses - Policy tabase/details/article-details.aspx?arti- Article (A52499) cleId=52499&ver=14&LCDId=33793&Con- trID=140&bc=AAAAAAAAgAAA&

Please Contact your MAC for any updates or changes to the Policy Article (PA) and the LCD regarding policy and general document requirements.

Medicare Learning Network® Content Disclaimer, Product Disclaimer, and Department of Health & Human Services Disclosure

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

Page 3 of 3 ICN MLN909480 August 2020