What makes contacts medically necessary

Just because you want to avoid out-of-pocket cost does not mean that your lenses can be deemed necessary. There must be adequate justification and documentation, along with a provision by the vision plan for this allowance. There are two types of necessary contact lens claims: for visual- and medical-necessity.

Visual necessity exists when glasses cannot provide a desirable outcome due to predictable optical side effects. The first step to know your candidacy for necessary contact lenses is to schedule an appointment with your eye doctor.

At that time, you will learn about your treatment options and any potential out-of-pocket costs should you proceed forthwith contact lens treatment. ReVision Optometry is the first practice in San Diego built from the ground up to provide services to patients with visually-necessary and medically-necessary contact lens needs. Chou previously established and directed a specialty-contact lens clinic in northern San Diego, 4S Ranch, which in was acquired by a private-equity affiliate.

This guide is designed to help you maneuver through vision insurance plans, learn which plans provide what coverage, and get a basic understanding of the procedural codes used for billing. A unique aspect of EyeMed is that vision improvement with contact lenses, even without a medical diagnosis, can be considered medically necessary without a refractive error requirement. On the other hand, Davis Vision requires that contact lenses must improve visual acuity by 2 lines AND meet a refractive error requirement.

Compared to other vision insurance plans, Superior Vision does not constitute high Ametropia alone as a requirement for medically necessary contact lenses. Irregular Astigmatism billed as the primary medical diagnosis does not qualify as medically necessary under VSP.

Irregular Astigmatism is considered a condition caused by an underlying disorder such as Keratoconus. Contacts with spectacle lenses to wear over contacts for the following conditions are a covered benefit as well:.

Medicare helps pay for either one pair of eyeglasses with standard frames or one set of contact lenses. This only applies to Medicare Part B for one-time use for the following:. With the proper testing, diagnosis, and billing codes, your role as an eyecare provider can transform the lives of your patients. For patients with underlying ocular conditions that impact vision, contact lenses are much more than a cosmetic choice—they are a necessary treatment option that meets their visual needs and provides the comfort and confidence to complete day to day tasks and enjoy leisure activities.

An ABN is a written notice a provider gives to a Medicare Part B beneficiary before providing items or services when the provider has reasonable knowledge that Medicare will not pay for some or all of the items or services. This is not a general or long-standing form, but rather a per-occurrence, per-procedure form and must be completed prior to providing the patient with services. The ABN requires that you explain what services or materials you are proposing to provide, why they may be denied by the carrier and the costs of the specific service or materials.

The ABN provides three options for patients: 9. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

If you are adapting an ABN for a commercial carrier, create a new form and substitute the word Medicare with your insurance carrier. In each option listed, you can get paid on the date of service rather than waiting for the carrier to make a coverage decision. It is always preferable to write a refund check to the patient than to manage the accounts receivable situation created by not collecting at time of service. Because an ABN form or its derivative for commercial carriers is never submitted to the carrier, you must use modifiers to let them know you have properly completed the ABN form.

Four common modifiers can be appended to the CPT codes for procedures that may be denied by the carrier. Depending on the service provided and the specific circumstances, the modifier can be either required by Medicare or voluntarily appended to the CPT code. Modifier GA: Waiver of liability statement issued as required by payer policy, individual case.

CMS will assign financial liability to the beneficiary should the services be denied. The financial liability will be legally transferred to the patient, and you can bill the patient for this service. Modifier GX: Notice of liability issued, voluntary under payer policy. When you append this modifier to a CPT code, it reports that you issued a voluntary ABN for a service that is statutorily excluded from Medicare reimbursement.

Medicare will reject non-covered services appended with GX and assign liability to the beneficiary. Since this is a voluntary ABN, the patient always has financial responsibility for the service. This usually refers to bandage contact lenses used to manage recurrent erosions and corneal abrasions. Verify with the insurance company what criteria are required for the diagnosis of keratoconus and grading of its severity. Also, determine if the insurance provider prefers that lenses be billed for separately or as a bundle.

After the fees, timeline, and expectations of the contact lens evaluation process have been discussed, it is important to have patients sign a written contract that includes an advance beneficiary notice ABN. ABNs require patients to make an informed decision on whether they or their insurance company will pay for the services and goods provided.

If the claim is denied, patients are aware that they are financially responsible. The written contract discusses all the charges involved in the treatment plan eg, office visits, warranties, lens upgrades, supplies needed, timeframe of the treatment plan. You may ask to be paid now because I am responsible for payment. These codes Table 1 are used to bill for the materials ie, contact lenses and may have a modifier for the right or left eye.

These codes are used on insurance forms and are universal. You may also have to indicate the quantity of lenses. Every vision insurance provider has its own expectations.