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That was the word from CGS Medicare鈥檚 Towanna Tripp during the payer鈥檚 January 21, 2021 鈥淔requently Asked Question鈥� webinar. She revealed the answers to four pressing community questions during the session, and we鈥檝e got the updates most applicable to eye care practices.

Question 1: Do MACs Need Prior Authorizations?

One way that many eye care practices maximize income is to get prior authorization for many services. This allows you to confirm that your work will be reimbursed, and can typically help you determine the patient responsibility. However, Tripp said, it鈥檚 not always required.

鈥淔or Medicare Part B, all services are allowed based on medical necessity,鈥� she said. 鈥淭his means you bill your services to us, and based on the diagnosis on your claim, we鈥檙e going to decide whether to allow that service. We often get questions requesting prior authorization for advanced imaging services like CT scans or MRIs. We do not require prior authorizations for these. The only things in Part B that do require prior authorizations are certain DME services and for certain Part A outpatient department services,鈥� she noted.

Tripp鈥檚 statement is supported by CMS. In MLN Bulletin SE0916, the agency notes, 鈥淢edicare coverage and payment for items and services is contingent upon a determination that an item and service:

• Falls within a benefit category;
• Is not specifically excluded from coverage; and
• The item or service is 鈥渞easonable and necessary鈥� unless specifically excluded from meeting this provision.鈥�

Note this eye care-specific exception: As of July 1, 2020, prior authorization is required for certain hospital outpatient procedures, Tripp said, and among these are blepharoplasty procedures. That鈥檚 because this service can be considered medically necessary or cosmetic, which is what prompted the prior authorization requirement, Tripp said. The hospital outpatient department submits the prior authorization request to ensure that the procedure can be paid after the service is rendered.

Question 2: When Can We Perform the Annual Wellness Visit (AWV)?

In some cases, patients with conditions like glaucoma or macular degeneration may only visit the ophthalmologist each year, not making time to see other physicians. Therefore, the ophthalmologist might opt to perform an annual wellness visit (AWV) to ensure that the patient鈥檚 overall health profile is taken into consideration. However, these services have very specific guidelines surrounding them, Tripp said.

鈥淏efore scheduling an AWV, check the patient鈥檚 eligibility information,鈥� she noted. 鈥淭he AWV is covered when the beneficiary is no longer within the 12 months after the patient鈥檚 Part B benefits eligibility date AND has not received an initial preventive physical exam (IPPE) or an AWV within the past 12 months,鈥� she said. 鈥淚f you try to bill an AWV within the patient鈥檚 first 12 months of beginning Part B, our system is going to reject that because the patient hasn鈥檛 been in the Medicare program long enough to have an AWV,鈥� she said.

Some patients may say they have been on Medicare for years but haven鈥檛 had an annual exam, but then you report an AWV and face a denial. In these situations, perhaps the patient forgot to tell you they had an AWV six months ago, because they didn鈥檛 realize that鈥檚 what it was. If it鈥檚 billed within 12 months of the previous one, the claim will be denied, she said.

To avoid these denials, you can check your MAC鈥檚 online system to determine when a patient is next available for another AWV, or the patient can call and check that information themselves, but it should always be checked before scheduling. 鈥淏ecause if we don鈥檛 pay for it, we deny it and we give it patient responsibility 鈥� and a lot of times, they complain and say they never had it and they don鈥檛 want to pay you, so it could be hard to get your money,鈥� she noted.

Question 3: Our Physician Rendered Postop Care Only 鈥� Why Are Our Claims Being Denied?

It happens from time to time: Patients may go to another city for a surgery, such as a cataract excision, and then return to their hometown, where your eye care specialist will handle the postoperative care. Getting paid for postop care only can be tricky, Tripp noted.

In these cases, physicians other than surgeons who are providing postoperative care should use modifier 55 (Postoperative management only) for procedures with global periods of 10 or 90 days, Tripp said. 鈥淩eport the date of surgery as the date of service (DOS), not when you first saw the patient.鈥� For instance, perhaps the patient had surgery on Jan. 1, but you didn鈥檛 see them until Jan. 9. The DOS is Jan. 1, not Jan. 9, she said. 鈥淚ndicate the 鈥榓ssumed鈥� and 鈥榬elinquished鈥� information in item 19 of the claim form, she noted.

鈥淭he receiving physician must provide at least one service before billing any part of the postoperative care,鈥� she noted. 鈥淪o, if the patient had surgery on Jan. 1, you can鈥檛 bill us on Jan. 2 for the postop care. You have to wait to see the patient first before doing that.鈥�

The surgeon who performed the surgery may forget to put modifier 54 (Surgical care only) on their claim. 鈥淭hey may have relinquished the postop care to your physician, but they forgot to bill their surgery claim with the 54 modifier, so when that comes in, we have no idea whether the surgeon relinquished their care until you bill your claim,鈥� Tripp said regarding the payer鈥檚 perspective. 鈥淏y this time the surgeon has already gotten paid, not only for the surgery but also for the postop. They got paid for the entire global package.鈥�

To correct this, you must contact the surgeon and let them know they made an error and received the money for the postop care. They will have to send a correction to the insurer鈥檚 overpayment recovery department so they can recoup that portion of the claim. 鈥淭hey have to bill it with the 54 modifier and we can adjust the claim and recoup our money back and once that鈥檚 done, you鈥檒l be able to bill your claim for the postop care,鈥� she said. 鈥淢ake sure you鈥檙e working closely with the surgeon鈥檚 office, and that they鈥檙e getting their info in as soon as possible, because even though they got paid for the postop care, your claim is being rejected for a billing error, so you鈥檙e on a time limit to get that claim into us within a year from the DOS so you can get your payment.鈥�

If the surgery occurred in another state, indicate that in block 19, she advised. Some issues stem from the fact that the surgery was in one state and the postop care was in another, which should be made clear to the MAC so the processors know to verify that the out of state provider billed the claim correctly as well.

Question 4: How Many Units Should I Submit When Using Modifier 50?

鈥淲hen billing the 50 modifier (Bilateral procedure) to report a bilateral procedure, performed in the same operative session, the unit (quantity field) must be 鈥�1,鈥欌�� Tripp said. 鈥淵ou鈥檙e only billing for one bilateral procedure, so therefore you should only be billing one unit, it鈥檚 as simple as that,鈥� she said.

Report the procedure on one line of the claim form, and if you use modifier 50, don鈥檛 also use the RT (Right side) or LT (Left side) modifiers, she said. In addition, if the code descriptor already uses the term 鈥渂ilateral,鈥� it doesn鈥檛 need modifier 50, since those are inherently bilateral. 鈥淭his isn鈥檛 usually required for X-rays,鈥� she said. 鈥淔or X-rays, you can just bill two units.鈥�