Ophthalmology and Optometry Coding Alert

Follow this strategy and earn $136 for each contact lens procedure.

Reporting the typical contact lens fitting codes won’t be enough to describe your eye care physician’s work fitting lenses for a patient with keratoconus — so knowing how to use 92072 is essential when you try to collect for this service. Read on for tips about how to properly use this code.

Prove Medical Necessity for Keratoconus Patients

Keratoconus is a chronic medical condition that causes the cornea to deviate from its typical orbital shape and instead thin out to create a conical shape, which impairs the patient’s vision. The eye care specialist can help improve the patient’s vision with the use of gas permeable contact lenses that are custom-fitted to fit over the patient’s enlarged cornea. Physicians who perform the fitting for these special contact lenses put in significantly more work than they would for a standard contact lens fitting in a healthy patient.

Example:  A 26-year-old patient presents with distorted and blurred vision along with glare and light sensitivity. The ophthalmologist diagnoses keratoconus (K18.601-K18.629) and fits special contact lenses to correct the problem. You know that 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) isn’t appropriate because the patient’s carrier considers it to be a refractive error correction.

Solution: To avoid denials when the ophthalmologist prescribes a contact lens to treat keratoconus, use 92072 (Fitting of contact lens for management of keratoconus, initial fitting). Based on the 2017 Medicare physician fee schedule, unadjusted for geographic location, you can expect about $136 for 92072. Keep in mind that it’s not only correct coding to report 92072 for this service, but it also pays about $40 more than you’d collect for the typical contact lens fitting code 92310.

Supplies: Because doctors use rigid, gas-permeable lenses to treat keratoconus, reporting 92072 for this service shows that the lens is for treatment of a medical condition, not a refractive condition.

“The gas permeable lenses are considered medically necessary and may be separately billable to Medicare and private payers, but local policies will prevail as to coverage and payment policies,” says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. “It may depend upon whether the ophthalmologist used a soft contact lens versus a hard gas permeable lens, which is more costly.”

Know These Payer Considerations

Another reason it’s important to report keratoconus with 92072 and not with 92310 is because many insurers refuse to cover contact lens fittings in otherwise healthy patients. For instance, Aetna’s policy says, “Most Aetna medical benefit plans exclude coverage of contact lenses and other vision aids,” but also adds, “Aetna considers services that are part of an evaluation of keratoconus or other corneal disorders associated with irregular astigmatism (e.g., keratoglobus, pellucid corneal degeneration, Terrien’s marginal degeneration, post-LASIK ectasia, corneal scarring) medically necessary.”

Therefore, if your payer follows the same guidelines as Aetna, you not only risk losing $40 if you erroneously report 92310 when treating a keratoconus patient, you actually risk the entire $136, since you’d collect nothing for a standard lens fitting in a healthy patient.