Medicare plans follow Medicare coverage and billing rules
Vision Care - 91538
Cataract surgery billing
Go to the medical/surgical services section for cataract surgery billing information.
For beneficiaries who have had a cataract removed but do not have an implanted intraocular lens (IOL) or who have congenital absence of the lens, the following are covered when determined to be medically necessary:
- Bifocal lenses in frames; OR
- Lenses in frames for far vision and lenses in frames for near vision; OR
- Contact lens(es) for far vision (including cases of binocular and monocular aphakia) AND lens(es) in frames for near vision to be worn at the same time as the contact lens(es) AND lenses in frames for far vision to be worn when the contacts have been removed.
- Replacement lenses, when medically necessary.
Tinted lenses (V2745), including photochromatic lenses (V2744) used as sunglasses, prescribed in addition to regular prosthetic lenses to an aphakic beneficiary
After each cataract surgery that includes an IOL, eyeglasses or contact lenses are not a covered benefit. The exception to this is for Medicare members.
Members who have two separate cataract surgeries cannot reserve the benefit after the first surgery and purchase two pair of eyeglasses after the second surgery.
Refer to the Policy Article above for information about non-coverage of replacement lenses for pseudophakic beneficiaries.
Anti-reflective coating, tints, oversize lenses
Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only when medical necessity is documented by the treating physician. When provided as a beneficiary preference item and billed with an EY modifier, they will be denied as not reasonable and necessary.
UV protection and coating
UV protection is considered reasonable and necessary following cataract extraction. Additional documentation beyond inclusion on the order is not necessary.
UV coating (V2755) is not reasonable and necessary for polycarbonate lenses (V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and necessary.
Lenses made of polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional vision in only one eye. In this situation, if eyeglasses are covered, V2784 is covered for both lenses. Claims that do not meet this coverage criterion will be denied as not reasonable and necessary.