Guidance on Providing Postoperative Cataract Eyewear

During my nearly 3 decades of experience in ophthalmic administration, I have focused on optimizing operational efficiency by reducing expenses and exploring new revenue streams. A strategic initiative for you to consider in the upcoming year involves establishing an in-house optical shop with the goals of enhancing your practice’s service offerings and profitability.

I advocate for the integration of ophthalmology and optometry practices to provide comprehensive eye care services. An integrated approach supports specialized care tailored to patients’ needs. Ophthalmologists handle medical and surgical evaluations and procedures, and optometrists manage routine vision care. In my experience, collaboration facilitates a seamless patient experience and supports on-site optical services, ultimately improving patient satisfaction and operational efficiency with an added revenue stream.

Venture Optical Management is a comprehensive optical management firm that supports optical practices through services such as inventory control, staffing, administrative support, and protocol development. The team collaborates closely with practices to create a modern, patient-centric optical shop that features the latest eyewear trends to help practices stay competitive and meet evolving patient expectations.

Tracy J. Kenniff, MBA, OCS

There are many reasons for your practice to participate in Medicare’s Durable Medical Equipment (DME) coverage of postoperative cataract eyewear. For one thing, Medicare incentivizes enrollees to choose a participating provider (ie, by offering better benefits), and patients pay the optical full retail price for all upgrades. Many also purchase additional pairs of glasses and refer friends and family members. Additionally, Medicare periodically adjusts its reimbursement fee schedule for inflation. For surgeons, billing for postoperative cataract eyewear provides a one-stop shopping experience for patients. For optometrists, it represents an opportunity to comanage patients with ophthalmologists.

Before proceeding, however, it is essential to become familiar with the enrollment, regulation, updating, and maintenance processes for credentialing. This article provides a general overview of the enrollment process and direction on where to find the necessary rules and requirements to make an informed decision.

UNDERSTANDING MEDICARE DME ENROLLMENT

Simply being a credentialed Medicare provider does not cover filing claims for postoperative cataract eyewear, which instead falls under Medicare DME. The billing process for postoperative eyewear is quite different from that for cataract surgery and subsequent aftercare. DME is a Medicare benefit that requires separate enrollment.

Furthermore, according to Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier standards,1 each optical dispensary that provides postoperative cataract eyewear must enroll separately as a DMEPOS supplier under its own National Provider Identifier (NPI). The supplier standards list all the requirements that an optical must meet to be a supplier.

The National Provider Enrollment DMEPOS Eastern and Western Region contractors assist practices with the application process, understanding the Medicare Provider Enrollment, Chain, and Ownership System, and processing DMEPOS enrollment applications. You can find your contractor on the Medicare fee-for-service provider enrollment contact list.2

It is important to remember that, if a practice operates multiple opticals, each location must apply for and receive its own unique NPI. Upon approving an application, the enrollment contractor will issue a distinct Provider Transaction Access Number for each NPI.

In most situations, Medicare pays for eyewear only following cataract surgery, and the patient must be enrolled in Part B to have the benefit.

ENROLLING IN MEDICARE DMEPOS

Once you review the DMEPOS supplier standards and are ready to become a Medicare DME supplier, consult the comprehensive enrollment checklist available on the CMS website, which outlines the necessary steps.3

REVALIDATIONS AND MAINTENANCE OF CREDENTIALING

Ongoing maintenance is required for each approved combination of NPI and Provider Transaction Access Number. To maintain billing privileges, revalidation of enrollment records is required by CMS—every 3 years for DMEPOS suppliers and every 5 years for other providers and suppliers. CMS reserves the right to conduct off-cycle revalidations for program integrity purposes. Failure to revalidate on time can result in the deactivation of your billing privileges. Revalidation information and other helpful tools are available on the CMS website.4

Another ongoing responsibility is to keep your enrollment information accurate and up-to-date. To avoid deactivation of your billing privileges, report any changes within 30 days of the event via the Provider Enrollment, Chain, and Ownership System or a CMS 855S form. These include but are not limited to a change of ownership, an adverse legal action, and a change in practice location.

RULES AND REGULATIONS

It is important that your staff understand the Medicare DME rules and regulations for dispensing postoperative cataract eyewear. DME consists of equipment and supplies ordered by a health care provider for everyday or extended use. It encompasses a wide range of items, including wheelchairs, oxygen masks, and eyewear following cataract surgery. The broad scope means that not all information in the CMS DME manual applies to eyewear, which can make navigating the information challenging. Reading the agency’s articles on local coverage determinations and policy for refractive lenses can help clarify the rules and regulations to follow when dispensing postoperative cataract eyewear.5-7

CMS issues contracts to companies to help administer the Medicare DME program. These companies, called Medicare Administrative Contractors (MACs), interpret the rules and regulations, develop policy training, assist CMS with the enforcement of regulations, and process claims. MACs are an excellent resource for your practice and can answer questions that you and your staff may have about the program. Two DME MACs manage the four geographic jurisdictions.8

CONCLUSION

The billing process for postoperative cataract eyewear under DME differs from physician services. For more information or clarification of the topics discussed in this article, refer to CMS’s website, policy articles, local coverage determinations on refractive lenses, and standard documentation articles as well as your MAC.

Authors’ note: The content of this article is for general informational purposes and reference only. It represents the authors’ interpretation and views and should be used solely as guidance. It is not an all-inclusive guide and is not intended to constitute legal advice. For final clarification, understanding, or questions, contact CMS and all corresponding entities.