Ophthalmology and Optometry Coding Alert

Cosmetic or medically necessary? Not all lens codes are created equal.

Even in the most experienced ophthalmological practices, contact lens coding myths abound. Is one of the following misconceptions harming your claims and imperiling your deserved reimbursement?

Myth: Coding for medically necessary contact lenses is the same as coding for elective contacts.

Reality: Many carriers, including Medicare, will not cover correcting of refractive error, including with contact lens prescriptions. If the contacts are prescribed to treat something else, look to one of these specific CPT® codes, 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.

For lenses for aphakia (absence of the natural lens), report one of the following:

• 92311 – Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, 1 eye
• 92312 – …corneal lens for aphakia, both eyes
• 92313 – …corneoscleral lens.

 For therapeutic contact lenses, report one of these:

• 92071 – Fitting of contact lens for treatment of ocular surface disease
• 92072 – Fitting of contact lens for management of keratoconus, initial fitting.

Contact lens management for keratoconus (a condition in which the cornea is unable to hold a round shape) is more labor-intensive than management of ocular surface disease – reflected in the fact that Medicare reimburses on average $38.31 for 92071, compared to $136.41 for 92072.

Note: For subsequent fittings for keratoconus lenses, CPT® directs you to report either an E/M (9921X) or ophthalmological management (9201X) code.

Refractive error: Prescription of lenses to treat refractive error – described by CPT® code 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) – is “non-covered by statute,” according to Medicare’s Billing and Coding Guidelines for Optometrist Services.

“Beneficiaries may be billed for these services,” say the guidelines. “The beneficiary should be notified these services are non-covered and informed of the cost the physician will charge for the service.”

Don’t miss: Include optical and physical characteristic specifications, such as power, size, curvature, flexibility and gas-permeability, in the contact lens prescription service. You should not consider prescription a part of the general ophthalmological services, according to the CPT® manual.

Contact lens fitting, on the other hand, includes instructing and training the wearer. It also includes the incidental lens revision during the training period, the CPT® manual states.

Myth: The codes are the same whether an ophthalmologist or an ophthalmic tech performs the fitting.

Reality: When an ophthalmologist, rather than a technician, provides contact lens prescription and fitting, you should choose from the CPT® 92310-92313 series. Include optical and physical characteristic specifications, such as power, size, curvature, flexibility and gas-permeability, in the contact lens prescription service. You should not consider prescription a part of the general ophthalmological services, according to the CPT® manual.

Contact lens fitting, on the other hand, includes instructing and training the wearer. It also includes the incidental lens revision during the training period, the CPT® manual states.

However: If a tech — not an ophthalmologist — provides the contact lens services, look to the following codes:

• 92314 — Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia (for prescription and fitting of one eye, add modifier 52)
• 92315 — … corneal lens for aphakia, one eye
• 92316 — … corneal lens for aphakia, both eyes
• 92317 — … corneoscleral lens.

Myth: There’s no need to give the patient an ABN for a contact lens fitting that Medicare is not going to pay for anyway.

Reality: Providing an Advance Beneficiary Notice (ABN) is voluntary for items that are statutorily excluded – like CPT® 92031 – but that doesn’t mean you shouldn’t do it.

According to CMS, the ABN is necessary “for the physician to bill a Medicare beneficiary for services which are always denied for medical necessity (e.g., visual fields for a patient without a covered diagnosis), frequency limited items (repeat of visual fields or other test more frequently than covered by the carrier or contractor), denial of Advanced Determination of Medicare Coverage (ADMC), and certain instances of upgrades.

The ABN is voluntary for items that are statutorily excluded (never covered by Medicare, such as refraction) or do not meet the definition of a Medicare benefit.

A Medicare patient undergoing a contact lens fitting needs to sign an ABN prepared by the practice in patient-friendly language informing him that he is responsible for the payment, although it may already appear redundant.

The ABN is a waiver signed by the patient to clarify that he needs to pay for the service. The patient’s signature and selection of acceptance of financial responsibility (via check box) in the event of non-coverage is important because it is assumed that once he signs it he has read and understands it and thus he can be held financially liable for the services. The patient may also select the option of no financial responsibility and the practice can then make the decision to provide the care or not to provide the care. A copy of the ABN must be provided to the patient as part of the guidelines determined by CMS. Make sure the ABN is written using layman’s terms and not CPT®/ICD9 codes. An estimate of cost to the patient must also be specified.

In the case of refraction for the purpose of keratoconus workup or contact lens fitting, there have been debates if the ABN is still necessary since, some argue, that you can simply tell the patient that Medicare doesn’t cover the procedure.

However: Some Medicare patients don’t know the refraction is not a covered benefit. If they sign the ABN, it can be explained to them in detail that refraction is not a benefit. But Medicare has stated that the ABN is not needed for refraction because Medicare never pays for refraction whereas they do sometimes pay for the services stated in your example.

According to CMS, the situations that call for an ophthalmologist’s patient to sign an ABN should remain the same when using the new form. “The ABN is only issued when the provider has an expectation of noncoverage,” CMS states.