Cracking the Code for Proper Payment of Lenses
The definition of medically necessary contact lenses should be clear by now, yet it continues to be parsed, segmented and redefined by third-party carriers. Practitioners may have to bear part of the blame for this as well, as some fall short in establishing and documenting true medical necessity for a contact lens fit with respect to specific pathologies. From the payer perspective, some waste and abuse have occurred, resulting in greater scrutiny and tightening of payer policies. Because of this, medically necessary contact lenses have different definitions based upon the carrier providing the benefits.
Providers must be familiar with the carrier-specific definitions and payer policies to properly prescribe and advocate for a non-elective contact lens prescription. Due diligence is critical in these cases to avoid any compliance issues.
The following codes describe the fit if performed by the physician according to the CPT:
- 92310: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.”
- 92311: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; a corneal lens for aphakia, one eye.”
- 92312: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; a corneal lens for aphakia, both eyes.”
- 92313: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens.”
(TIP: While the 92313-code description does not specify unilateral or bilateral, the Centers for Medicare and Medicaid Services (CMS) indicate that it should be considered a unilateral fit.)
Other important codes include:
- 92071: Fitting of contact lens for treatment of ocular surface disease. (This is considered a unilateral code.)
- 92072: Fitting of a contact lens for management of keratoconus, initial fitting.8 Because this is a bilateral code, make sure to report materials in addition to this code using either 99070 or the appropriate Healthcare Common Procedure Coding System (HCPCS) Level II material code. According to the CPT, “For subsequent fittings, report using evaluation and management service or general ophthalmological services.” For every follow-up visit, use a 9921X or 92012 code to follow the keratoconic cornea—remember, you are following the keratoconic cornea, and the contact lens is just the treatment paradigm.
In many situations, “incidental revision of the lens during the training period” and “with medical supervision of adaptation” are both accomplished during the first post-contact lens dispensing visit. Once the proper vision and comfort criteria are met and you have either ordered the final lenses or have provided the patient with their contact lens prescription, the patient can be considered fit for the contact lenses and the service period for that particular code is over. Should complications arise, the best way to bill for office visits is by using the established patient ophthalmologic (9201X) or evaluation and management (9921X) codes because you are following or managing an ocular condition, not performing a contact lens check.
Practitioners must remember to code properly for the materials. These HCPCS Level II codes specifically describe a scleral lens, followed by the 2018 CMS National Average reimbursement amount:
- V2530: contact lens, scleral, gas impermeable, per lens ($211.81)
- V2531: contact lens, scleral, gas permeable, per lens ($555.28)
Other material codes that may be applicable, depending on the technology, include:
- V2599: contact lens, other types (N/A)
- V2627: scleral cover shell ($1,501.39)
These are all based on a per-lens reimbursement amount, and the lens type and V codes used must match. Many carriers now request invoices as well. Finally, make sure not to confuse coverage with reimbursement or fees. Your fees should be based on a consistent methodology across the patient spectrum without bias or discrimination. Remember the “golden rule”: one fee per CPT code, no matter who is paying. A patient’s benefits for materials as paid by a third party and your fees are two separate issues.
E2E Medical Billing (E2E) can assist you in increasing your reimbursement by using exact codes and modifiers for service provided. Our team is having a great experience in optometry medical billing. We can take care of complete end-to-end medical billing function while you can focus only on your patients. To know more about the service offered, you can write to us at [email protected] or call us at 888-552-1290