How do I file DMERC insurance claims?

Submit DMERC insurance claims.

A copy of the DMEPOS supplier standards should be handed out to each patient.

Create Transaction for the glasses and lenses being purchased.

Create Transaction for the glasses and lenses being purchased.

Each service must be broken down individually by right and left eye.  The CPT code has a modifier for each eye (RT or LT).

Note:  Up to 3 modifiers can be entered in the CPT line.

Note:  If there are any services above and beyond the frame allowance or CR-39 lenses, two claims must be submitted.  One claim is for the covered services and one claim for the non-covered services, using EY and GA modifiers.  In OD Link, you can use the "omit" button in the claim or 1500 Form to separate the line items on one transaction into two different claims.

Claim for Covered Services - highlights show differences from regular Medicare claims

Claim for Covered Services - highlights show differences from regular Medicare claims

Box 14 and 15 are left blank.

Yellow Highlights:

Box 17, 17b, 24J, 31, 33, 33a - Referring physician:  In the case of billing glasses, the physician performing the follow up visits is referring the patient to receive the glasses.  This is NOT the physician who performed the cataract surgery.

Green Highlights:

Box 19 - Enter the name of the physician who performed the cataract surgery, their NPI and the dates of the surgeries for each eye.

Box 21 - The diagnosis code must be V43.1 (Pseudophakia), indicating cataract surgery.

Orange Highlights:

Box 24B - The Place of Service must be 12, indicating the patient's home where they will wear the glasses.

Box 24D - This section should include the frame CPT code (V2020) and lens CPT code (V2303).  Check the Medicare website for frame allowance.  Medicare only covers CR-39 single vision, bifocal or trifocal lenses.

Box 32 must remain empty.

Red Arrow - Use the blue "omit" button to remove items from this claim.  This can be done on the Red 1500 form or in the Claim Details for this claim.

Claim for Non-Covered Service - the second claim is only necessary if the patient is receiving services not covered by Medicare.

Claim for Non-Covered Service - the second claim is only necessary if the patient is receiving services not covered by Medicare.

The only changes from the above Covered Services claim are within box 24 D.

The code on the second claim for the non-covered portion of the frame should be V2025, deluxe frame.

All services must be broken down individually per eye, for example, for anti-glare, you use V2750.RT and V2750.LT.

Any non-covered service must be billed with an EY modifier; this modifier indicates that the services are not covered and the patient agrees to pay.

The patient must sign an ABN form for non-covered services.  The GA modifier indicates that the ABN form has been filled out and should be kept on file in the office.

Both the EY and GA modifieres need to be on each non-covered service line (for example, for anti-glare you would have on one line:  V2750.RT.EY.GA and V2750.LT. EY.GA).

Red Arrow: Notice, to create this claim, you can change which transaction line items are "omitted."  This can be done on the Red 1500 form or in the Claim Details for this claim.

Advance Beneficiary Notice of Nonconverage (ABN) Form

Advance Beneficiary Notice of Nonconverage (ABN) Form

Click Here to get a copy of the ABN official booklet and page.

Claim Detail Window

Claim Detail Window

You can see the same information in the Claim Detail window.