Despite a decline in profitability for refractive corrections, specialty practices are booming as the demand for specialty contact lenses increases.
Here, we take a deep dive into the world of coding for medically necessary and specialty contact lenses because it often differs based on the carrier and the contract language you must abide by.
Many make medically necessary contact lenses a profit center in their practice, sometimes charging $2,000 to $3,000 for a medically necessary contact lens “package” consisting of professional services and materials, even if the patient has coverage for those services under a contracted plan that may reimburse much less.
However, a practitioner contracted with a plan cannot ignore one portion of a plan’s coverage. When you provide specialty contact lens services for a patient, you must use all of their coverage benefits, even if it doesn’t reimburse as much. Providing selective benefits when you are a contracted provider and the patient has coverage can create significant exposure for audit and financial penalties.
Code Services Correctly
The CPT’s contact lens fit section begins: “The fitting of a contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.” These codes describe the fit if performed according to the CPT, all of which begin with, “prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation”:
- 92310: corneal lens, both eyes, except for aphakia
- 92311: corneal lens for aphakia, one eye
- 92312: corneal lens for aphakia, both eyes
- 92313: corneoscleral lens
Note: While CPT’s 92313 code description does not specify laterality, the CMS indicates that it is considered a unilateral fit.
Additional useful codes include:
- 92071: Fitting of contact lens for treatment of ocular surface disease (considered a bilateral code).
- 92072: Fitting of a contact lens for management of keratoconus, initial fit. (Because this is a bilateral code, also report materials using either 99070 or the appropriate HCPCS Level II material code. According to the CPT, “For subsequent fittings, report using E/M service or general ophthalmological services.” For every follow up, use a 9921X or 92012 code to follow the keratoconic cornea. The contact lens is the treatment paradigm.)
In many situations, revision of the lens during the training period and medical supervision of adaptation are accomplished during the first dispensing visit. Once you have either ordered the final lenses or provided the patient with their prescription, the patient is considered fit for the lenses, and the service period for that particular code is over.
What’s Wrong Matters
In addition to medical carriers, many managed vision care plans provide coverage for medically necessary contact lenses.
These clinical conditions typically have coverage: aphakia, nystagmus, keratoconus, aniridia, corneal transplant, hereditary corneal dystrophies, anisometropia ≥3.00D in any meridian, high ametropia ≥10.00D in any meridian, irregular astigmatism, achromatopsia, albinism, polychoria, anisocoria (congenital), pupillary abnormalities.
Should complications arise, bill for office visits using the established patient ophthalmologic (9201X) or E/M (9921X) codes because you are managing an ocular condition or complication, not performing a contact lens check.
Materials Are Separate
Typically, we use only a few HCPCS Level II contact lens material codes:
- V2530: contact lens, scleral, gas impermeable, per lens
- V2531: contact lens, scleral, gas permeable, per lens
- V2627: scleral cover shell
- V2599: contact lens, other type (N/A)
These are all based on a per-lens reimbursement, and the lens type and V codes must match. Many carriers now request invoices to support the lenses provided.
Lens advances are allowing us to treat a broader array of diagnoses with better outcomes; knowing how to code and bill properly is just as important.
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