What eye services will Medicare cover and how was recently clarified by the Center for Medicare and Medicaid Services (CMS).

What Does Medicare Actually Cover?

Medicare Part B doesn’t normally cover normal services like exams and glasses, but it will cover services treated illness or injury. There are three requirements for coverage:

• They must fall within a “statutorily defined benefit category”.
• The service must be reasonable and necessary for the diagnosis of treatment or injury, or to improve a malformed body part’s functioning.
•  The diagnosis and service cannot be excluded from coverage.

Several services, such intraocular lenses (IOL), glaucoma screenings, and others, for example, are covered depending on the diagnosis and service.

Medicare and Conventional IOLs

IOLs implanted for cataracts replace the natural lenses. Glasses and contact lenses are out, but Medicare will pay for a conventional IOL, the facility and experts required to insert the IOL, and eyeglasses or contact lenses a prosthetic devices.

Medicare and Presbyopia and Astigmatism-Correcting IOLs

Medicare says, “Presbyopia and astigmatism are common eye problems corrected by presbyopia-correcting IOLs (P-C IOLs) and astigmatism-correcting IOLs (A-C IOLs). A P-C IOL or A-C IOL provides what is otherwise achieved by two separate items or services:

• An implantable conventional IOL (one that is not P-C or A-C) that Medicare covers, and
• The surgical correction, eyeglasses, or contact lenses to correct presbyopia or astigmatism that”

Cataract Removal and Medicare

CMS wants you to report the correct codes in the table below:

*      Physicians should bill HCPCS code V2632 in an office setting only for the payable conventional IOL functionality of the P-C or A-C IOL.

** V2787 should be billed to report the non-covered charges for the A-C IOL functionality of the inserted intraocular lens. Additionally, note that V2788 is no longer valid to report non-covered charges associated with the A-C IOL. However, this code continues to be valid to report non-covered charges of a P-C IOL.

NOTE: Cataract removal codes are mutually exclusive and billed only once per eye. For moreinformation, refer to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 8, Section D.

Medicare and Glaucoma Screenings

Medicare covers annual glaucoma screenings for beneficiaries in at least one of the following high-risk groups. Beneficiary deductible and copayment applies for the following high-risk groups. :

• Individuals with diabetes mellitus
• Individuals with a family history of glaucoma
• African-Americans age 50 and older
• Hispanic-Americans age 65 and older A covered glaucoma screening includes:
• A dilated eye examination with an intraocular pressure measurement
• A direct ophthalmoscopy examination, or a slit-lamp bio microscopic examination

Medical record documentation must show the beneficiary is a member of one of the high-risk groups. The documentation must also show you performed the covered screening services. Include diagnosis code Z13.5 on your claim.

Other Medicare Covered Services

Eye exams to evaluate patients for signs of disease in patients with diabetes or disease are covered, along with annual examinations for asymptomatic diabetics.

Medicare generally covers eye prostheses for patients with absence or shrinkage of an eye due to a birth defect, trauma, surgical removal. It also covers polishing, resurfacing, along with replacement after five years.