Keratoconus patients often present optometrists with a few challenges. First, it can be very difficult to provide clear, comfortable vision without investing considerable chair time.
The second great challenge of keratoconus patients: Receiving proper reimbursement for the time invested. Although we clearly recognize keratoconus as a medical condition, many medical carriers and refractive carriers don’t recognize it as being medical in nature. (One notable exception is VSP, which has specifically defined benefits for keratoconus.)
This brings up a critical concept: You cannot create coverage for a patient where no coverage exists. If the patient doesn’t have coverage (benefits) for keratoconus, they simply will have to pay out of pocket.
Diagnosis and Initial Fit
Diagnosis of keratoconus is typically suspected during a routine exam, and then confirmed with corneal topography and/or pachymetry. Medical carriers vary considerably in topography reimbursement. Unfortunately, many won’t pay for the procedure, regardless of your appeals.
Once you confirm the diagnosis and counsel the patient, finalize your decision to fit the patient in contact lenses. The first step where many offices fail to bill properly is by using the wrong code. The code 92070, for fitting of a contact lens for medical or therapeutic purposes, including supply of lens, is a poor choice for keratoconus and should not be used.
A better approach: Bill the code for contact lens fitting (92310) and append modifier -22 (Increased Procedural Services) to alert the carrier to the greater amount of time and complexity for this procedure. (Use of the -22 modifier allows you to legally violate the “one fee per CPT code” rule.) Set your fee appropriately to cover your time for the fit and subsequent visits up until you issue the final contact lens Rx. Expect to submit further documentation to the carrier to justify this higher fee. A letter of explanation, including full color topographic maps, often fulfills this requirement.
Remember to always bill for the lens materials separately using the appropriate Level II HCPCS V-codes (such as V2513 or V2531, because you’ll often use a gas permeable extended wear lens).
Refitting and Monitoring
CPT contact lens services states, “The fitting of contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.” In addition, CPT defines 92310 for contact lens fitting: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.” In most cases, “incidental revision of the lens during the training period” and “with medical supervision of adaptation” are accomplished during the post contact lens dispensing visits. Once the proper vision and comfort criteria are met, the patient can now be considered fit for the contacts and a “final Rx” issued.
If complications arise, the most appropriate way to bill for office visits is using the established patient evaluation and management (99000) codes. Keep in mind that when billing the medical carrier for these office visits, be sure to use the appropriate diagnosis for the corneal condition you are monitoring: Remember, you’re not performing a contact lens follow-up; you’re monitoring the corneal condition, not the lenses!
Never consider your fitting fee to be a global, year-long obligation to provide unlimited service at no charge. If you refit a patient, and it is not just an “incidental revision of the contact lens,” then another 92310 is an appropriate code to bill, along with the appropriate materials V-code for lens supply.
Last but not least: Don’t make the mistake of discounting your services if the patient has to pay directly; bill all parties equally and without bias.
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