Ophthalmology and Optometry Coding Alert

When prescribing a contact lens to treat keratoconus (371.60-371.62), sometimes ophthalmology coders use 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). Although 92310 is the correct code for prescribing contact lenses, it is not the correct code when the lens is needed to treat keratoconus. To avoid denials, use 92070 (fitting of contact lens for treatment of disease, including supply of lens).

Fitting a contact lens using 92310 is for treating a refractive error, not a medical condition. Medicare doesnt cover the treatment of refractive problems, and neither do many private health plans (unless they have vision riders). Medicares fee schedule does not include 92310.

Medicare doesnt pay for correction of refractive error by any method, says Raequell Duran, president of Practice Solutions, a coding and compliance consulting company based in Santa Barbara, Calif., who specializes in ophthalmology. This includes spectacles, contacts and laser surgery.

If a patient has keratoconus, use code 92070, which includes the contact lens itself. Keratoconus is a disease in which the central or paracentral cornea undergoes progressive thinning and bulging, so that the cornea takes on the shape of a cone, according to the American Academy of Ophthalmology. Some cases of keratoconus are sufficiently mild, at least for a time, for the vision to be corrected adequately with glasses. However, hard or gas-permeable contact lenses are far more helpful in all but the mildest cases.

The kind of contact lens used to treat keratoconus is a bandage contact lens. In patients without corneal disease and with natural lenses, neither Medicare nor most private health plans cover contact lenses without vision riders. But using 92070 in a patient with keratoconus shows that the lens is for treatment of a medical condition, not a refractive condition. Therefore, you can bill the supply to your regular Medicare carrier, not to the Durable Medical Equipment Regional Carrier.

When a more expensive, hard contact lens must be used to treat the keratoconus instead of a disposable lens, you should submit your claim with a copy of the invoice for the lens.


Use 92070 For Other Conditions


Code 92070 can be used for other conditions in addition to keratoconus. Its up to the physician to decide when a medical condition warrants a contact lens, explains Heather Loveland, CPC, president of Physicians Advantage, a Hendersonville, Tenn.-based coding and reimbursement consultant who specializes in optometry and ophthalmology. For example, sometimes a bandage contact lens is used to protect the eye after a corneal abrasion (918.1). A thin plano lens would be used, Loveland says. A bandage contact lens would be needed after a corneal transplant.

In addition, many physicians use a disposable bandage contact lens to protect the wound site following cataract surgery, Duran says. However, the consultant notes, this cant be billed at all because it is used during the postoperative period and would be considered part of the practice-expense portion of the global surgical fee.


Billing for Aphakia


If a patient doesnt have his or her own natural lens (aphakia, 379.31 or 743.35), and you are fitting a contact lens for refractive error correction, do not use 92310. Use 92311 (prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye), 92312 (... corneal lens for aphakia, both eyes) or 92313 ( ... corneoscleral lens). Medicare will pay for contact lens fitting and supply for patients with aphakia.

Most Medicare carriers have established guidelines for how often they will replace a contact lens for an aphakic patient, says Lise Roberts, vice-president of Health Care Compliance Strategies, a coding and compliance consultant based in Jericho, N.Y. For example, most carriers would not expect to receive more than one claim per year per aphakic eye, she says. Billing more frequently than your carrier guidelines allow means they may deny the claim because it is being billed too frequently. Or, Medicare may suspend the claim and request additional information before processing. Unfortunately, it is easier for them to deny the claim so that the burden of demonstrating medical necessity for the frequency is placed on the provider, Roberts says. These claims have to be appealed through the normal Medicare appeals process.