Ophthalmology and Optometry Coding Alert

Tip: If a tech does the fitting, your coding strategy changes.

Experienced ophthalmology coders know that getting claims paid for contact lenses and other prescriptive medical devices can be one of the most vexing challenges in a typical workday. Here's our expert advice to help you steer clear of common errors and get on the path to contact lens claims success.

1. Home In on Codes for Lens and Fitting

When an ophthalmologist, rather than a technician, provides contact lens prescription and fitting, you should choose from the following codes:

• 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
• 92311 -- ... corneal lens for aphakia, one eye
• 92312 -- ... corneal lens for aphakia, both eyes
• 92313 -- ... corneoscleral lens.

Example: For most patients, you should bill the initial fitting with code 92310. CPT® guidelines: You should 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.

2. Remember Coding Options Change for Techs

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.

Watch for: Medicare does not cover 92310 and 92314, warns Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y.

3. Watch Descriptor for Unilateral vs. Bilateral

You have to be alert to whether you should bill contact lens procedures as bilateral or unilateral.

Code 92310 specifies "both eyes," so if you only do one eye, code 92310 with modifier 52 (Reduced services), per CPT.

"A reduced procedure means that the service did not include all of the required elements because of a 'choice,' usually because the entire service was not needed," explains Rena Hall, CPC, a biller and coder with a practice in Kansas City, Mo.

But the codes for aphakic patients differ based on whether you fit one or both eyes.

Example: Report 92311 when an ophthalmologist fits one eye for an aphakic patient and 92312 if she fits both eyes.

4. Consider Supply Codes and Charges

CPT® guidelines state that you may include contact lens supply as part of the fitting service, or you may report supply separately. To report a separate supply code, look to the V2500-V2599 series (Contact lens ...), which describe the materials you use for the case.

All of these V codes are monocular (per lens), so if you treat both eyes, you should report two units of the applicable V code. You may also append modifiers RT (Right side) and LT (Left side), depending on the payer's preference.

5. Treat Follow-Up as Office Visit

To report the follow-up of successfully fitted extended-wear lenses, bill it as a general service and use a code such as 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient).

6. Be Sure Your Documentation Makes the Grade

The ophthalmologist needs to document the proper measurements for correct contact lens fitting, and document their findings for base curve, diameter, and power of the lens.

As a precaution, you may document what type of lens you dispensed, the date, the dispensing person's signature, and the signature of the person picking up the lenses, but not every plan requires this. Example: Medicare requires the patient's signature but not the dispenser's. Still, good office policy would require the dispenser to initial and date the delivery of the lenses.

And don't forget to document the diagnosis that supports medical necessity for the lenses.

For example, an aphakic patient may merit one of the following codes:

• 379.31 -- Aphakia
• 743.35 -- Congenital aphakia
• V43.1 -- Organ or tissue replaced by other means; lens (pseudophakia).