Noelle Creamer

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-Medicare claims for eyeglasses after cataract surgery are the single most complicated claims to file, according to Kevin Corcoran, COE, CPC, FNAO, president of Corcoran Consulting Group.  

During a recent presentation titled, "Eyeglasses after cataract surgery-how to get paid," Corcoran, a reimbursement consultant, talked about general guidelines for filing claims and mistakes commonly made in the process. 

"In a practice, auditors will find that 70% to 80% of Medicare claims are filed on target," he said. "There's even better accuracy in an ambulatory surgery center. But in the optical shop, chances are good that none of the claims is accurate." 

Corcoran classified claims in four groups: things that are covered all the time; things that are never covered; things that may be covered once in a while; and things that are partially covered. 

Claims for post-cataract eyeglasses and contact lenses are not handled by local Medicare carriers, but rather by Durable Medical Equipment Regional Carriers. There are four regional carriers. Providers must submit claims regionally according to the beneficiary's address-not the pro-vider's business address. 

"Statutory coverage is sometimes a surprise to people," Corcoran said. "It says that Medicare beneficiaries are entitled to one pair of conventional eyeglasses or contact lenses after each cataract surgery with the insertion of an IOL. That's the law." 

The second part of the equation is Part B of the Social Security Act, which says they only pay for things that are "medically necessary," he said. 

"You're the boss; you're responsible," Corcoran said. "Make a good call. You decide what's medically necessary. What's the patient entitled to? It's the most subtle part of the whole thing." 

"The supplier must have an order from the treating physician before dispensing," Corcoran said. The prescription must specify the prescription itself, the name, the diagnosis, items you must have-not would 

to have-and the physician's original signature and date in ink. 

The prescription must be clear on what is a "must have" and what is cosmetic or for comfort. Corcoran gave some examples, such as a patient with one eye or a child who needs polycarbonate lenses-both are medically necessary for eye protection. 

"A patient who has been using executive bifocals has become habituated to them," he said. "You'll make them crazy if you switch them; they're medically necessary." 

Modifiers must be added correctly. For example, the KX modifier means payable.  

"KX is used for items that may be covered but are, this time, a must have," Corcoran said. "We've got to have it and it's ordered on the prescription." 

Conversely, EY modifier items are not payable and will cause the claim line to be denied.  

"EY is for an item not ordered by the physician, but something the patient wants to add on for personal reasons," Corcoran said. "The patient pays us. 

"Everything goes on the claim form, even stuff Medicare doesn't pay for," Corcoran explained. "You're required to give an advance beneficiary notice (ABN). Yes, opticians hate paperwork, and there are lots of items to put on each claim form, but everything has to be listed on the claim. 

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San Bernardino, CA-Medicare claims for eyeglasses after cataract surgery are the single most complicated claims to file, according to Kevin Corcoran, COE, CPC, FNAO, president of Corcoran Consulting Group.

How to get paid for eyeglasses after cataract surgery

"Ophthalmology was a natural choice," he said. "I grew up in the business and have been around it all my life." 

But another love fostered by his father-the outdoors-gives Dr. Loden a break from ophthalmology that relieves his stress. His favorite outdoor pastime is duck hunting. 

Early in his teens, the future Dr. Loden began competing in duck-calling contests. He learned this art from the expert callers with whom he hunted. "And I practiced a lot," he added.  

He won the Tennessee state senior division at age 14 and became a "retired" Tennessee state champion at age 19. (He had won the championship three times by then, and they wouldn't let him compete anymore!) 

In high school, the future Dr. Loden competed on the rifle team. He won the state championship for small bore rifle. "I went to the Olympic training camp," he said, "but I realized it's difficult to make any money at competition rifle shooting. Instead, I concentrated on college and medical school. 

"Hunting is a stress reducer for me," said Dr. Loden. "I can spend lots of time by myself, or it can be very social: four or five guys go and watch for ducks and talk and joke until we see birds. Then, there's all the fun after shooting-sending the dogs to retrieve, splashing in the mud. ...We're all little boys at heart; we love dogs and guns." 

Dr. Loden's dog, Peeler, is a professionally trained 5-year-old black Labrador retriever. Peeler spends March to September with trainers and is a qualified master hunter and an open qualified field trial dog. He just passed the Canadian National Master Hunt test. 

"I joke that I have a college-educated dog," said Dr. Loden. His dog is great with the family, too, and goes to work with Dr. Loden every day. 

Duck season in Nashville is all of January, which works out well for Dr. Loden, he said, because his cataract surgeries drop off significantly after the first of the year. He hunts at a convenient location a little more than an hour from his practice so he can often hunt before or after a full day of work, he said. 

Dr. Loden said he belongs to several hunting clubs and has hunted with some of the same men for 30 years. He added, "A lot of my fellow hunters are my father's age. My dad always said, 'If you can still walk and see, you can duck hunt.' " 

For the past several years, Dr. Loden has made a trip to Canada in the fall to hunt Canada geese and ducks for 3 or 4 days. He also has been on hunting adventures in South America and South Africa and said he enjoys an annual fishing trip to the Florida Keys.  

Dr. Loden said he is interested in conservation of the wetlands and is a member of the Tennessee Wildlife Federation, Delta Waterfowl, and Ducks Unlimited. He said he is concerned about urban sprawl around Nashville and development in other watershed areas eliminating habitat for wildlife and polluting waterways. He owns 500 acres on Tennessee's Buffalo River and also hunts at a leased property in Grassy Lake in Southern Illinois, he said. 

James C. Loden, MD, an ophthalmologist in private practice in Nashville, learned much from his father, who also was an ophthalmologist.

Family traditions

Dr. Iliff is a member of a relay team that swam the English Channel round-trip in September. He is 62. 

As many children growing up in Annapolis do, Dr. Iliff spent ample time either in or on the water. Annapolis is situated along several rivers and the Chesapeake Bay, where favorite pastimes are swimming, fishing and crabbing, and sailing. 

"I always swam, but I never had any formal instruction," said Dr. Iliff. "I played soccer my freshman year in college but decided at the end of the season to walk onto the swim team." 

He swam in college but left the sport behind as he finished medical school and started his practice. 

"It was the 1984 Olympics that rekindled my interest in swimming," said Dr. Iliff.  

He and Sally joined a YMCA Masters Swim group in Anne Arundel County and began swimming and competing. They have been with their coach now for 20 years. 

"Jack's a much better swimmer than I am," said Sally. They agree that they are not competitive with each other; they only encourage one another. Dr. Iliff credited his wife for getting him to practice when it's tough to get out of bed. "Practice can be boring and the pool so cold at 6 a.m.," he added. 

With their Masters Swim group, they compete in YMCA Nationals each spring, and both have brought home many individual first-, second-, and third-place finishes. In 2005, Dr. Iliff placed first in the country (All-American) with a 400-Meter Individual Medley (IM) swim. The IM requires all four strokes-butterfly, backstroke, breaststroke, and freestyle-in one race. This event was, for that year, number two in the world and eighth best overall ever recorded in Masters competition.  

"We do well in our age groups," said Dr. Iliff. "We can't help it if better swimmers don't show up to compete." 

The Arundel Breakfast Club (ABC) is the informal group with which they swim. 

"The ABC is a group of friends," explained Dr. Iliff. "We just fell in with each other." 

For W. Jackson (Jack) Iliff, MD, swimming has always been part of life. It wasn't until he was in his 40s that he became involved in competitive swimming. And, it wasn't until 2005-2006 that swimming became an extraordinary accomplishment.

Making a splash

Of these, his primary interest is growing grapes. Dr. Cooper credits his father with instilling in him a respect for the land and an appreciation of farming. 

"I always had an idea to have a farm, and I knew I needed it to be within an hour of my practice in Richmond," he said. "I began to study soil and topography maps." 

He found a 120-acre farm to buy in Louisa, which is between Richmond and Charlottesville.  

"I began digging holes and planting vines," Dr. Cooper said. The property had a shell of a metal building, which he turned into the winery. That was 10 years ago and today, his farm includes 12 acres of vines. 

His partner in this venture is Jacquelyn Hogge, MD, who practices diagnostic radiology in Richmond. 

"As we worked to improve the winery, I realized I was a weak link," Dr. Cooper said. "We brought on board winemaker Graham Bell. You have to let someone better do it and put your ego aside." 

Cooper Vineyards produces several white wines, including an award-winning Viognier and Coopertage Blanc. They also make red wines, including Merlot, Cabernet Franc, and Norton.  

Norton is a native Virginia grape. Cooper Vineyards now features a sweet ice wine called Noche Chocolate, which has the flavor of berries and is infused with chocolate. Their Ice Vidal, Vida, has delicate apricot flavors. 

"It's a fun thing, winemaking," said Dr. Cooper. "Trying new things, new blends. We (Dr. Hogge, Bell, and Dr. Cooper) have blind tastings and share our thoughts.  

"While larger winemakers work to keep their signature flavor consistent from year to year, smaller wineries, like ours, don't," he continued. "We adjust each season and make the best wine from the grapes each year." 

Cooper Vineyards practices gentle fruit handling, bringing in the grapes in "lugs" of 30 pounds instead of tons at a time. This way, not as much crushing occurs, Dr. Cooper said. They do a lot of the labor themselves; pruning, for example, requires specialized knowledge.  

Harvest is around Labor Day. It lasted 2 months last season. 

Geoffrey Cooper, MD, FACS, a comprehensive ophthalmologist in solo practice in Richmond, VA, sees his hobby of winemaking as an adventure with three parts: growing grapes, making wine, and marketing the wine.

Author | Noelle Creamer

Articles

Family traditions

Making a splash

Virginia vines and wines

How to get paid for eyeglasses after cataract surgery