Question: When our ophthalmologist performs Lipiflow, we bill our Medicare contractor the unlisted CPT because the Category III reimbursement does not cover the expense of the supplies to perform this service. Medicare paid with the unlisted code, other payers do not. Are we able to charge the patient if the payer that we bill does not have coverage for this service?

Answer: When there is a defined CPT code that meets the procedure performed, physicians should submit that code. In this case the Category III code 0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral should be billed instead of the unlisted procedure code. If Medicare should audit, they can recoup payment.

When determining coverage for Category III codes, ask for the allowable and confirm coverage. If a payer you are contracted with has coverage for the Category III code, you are obligated to file and accept the contracted rate, even if it does not cover expenses.

For Medicare Part B with no coverage, the Academy recommends you obtain an advance beneficiary notice (ABN) from patients, informing them that they may have to pay out of pocket. Append modifier -GA, which indicates you have the ABN on file. Commercial payers may require prior authorization.