Question: When a patient elects to upgrade his standard frame to a deluxe frame after cataract surgery, can a physician charge the differential even though he accepts assignment of benefits?
Answer: Yes, you can. Medicare covers up to one pair of eyeglasses or one set of contact lenses after cataract surgery with IOL implantation. As such Medicare will only pay for the standard frames but if a beneficiary chooses to upgrade to a deluxe frame, the participating provider or supplier (ophthalmologist, optometrist or an optician) may charge the beneficiary the difference between the standard frame and the deluxe frame charges for what he/she may have charged from his/her private pay patients, in addition to 20% coinsurance and/or any applicable deductible on glasses with standard frames, even though the provider accepts assignment if the following conditions are met:
a) Explain the beneficiary the price and difference between standard and deluxe frame and issue an ABN (Advanced Beneficiary Notice) and have it signed.
b) Have a statement signed and dated on patients chart which states:
The beneficiary[name], [Medicare Id#], was fully informed that an extra charge is being made by the physician or supplier for the upgraded frames and that this extra charge is not covered by Medicare, and that the standard frames are available for purchase but beneficiary declined the option to go for standard frames and instead chose the deluxe frames.
c) Once patient choses the deluxe frame, the physician or the supplier is then required to submit claims to medicare indicating the purchase of deluxe frames as 2 separate line items on the claim form; his/her actual charge for the standard frames and his/her charge for the deluxe frame (differential).
For example: On Line 1, V2020 for the cost of standard frames and the Medicare approved amount; and on line 2,V2025 (Deluxe Frame) for the difference between the charges of deluxe frame and standard frame.
Once the claim is processed, Medicare summary notice will reflect Code V2025 as non covered charges.