Ophthalmology and Optometry Coding Alert

Find out which service is often underpaid by carriers

CPT has altered the contact lens section -- here are the crucial changes you must know. 

CPT 2006 deleted 92330 (Prescription, fitting and supply of ocular prosthesis [artificial eye], with medical supervision of adaptation) and 92335 (Prescription of ocular prosthesis [artificial eye] and direction of fitting and supply by independent technician, with medical supervision of adaptation).
 
New instructions direct you to report an E/M code (99201-99215) or general ophthalmological service codes 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) and 92014 (... comprehensive, established patient, one or more visits) in place of the deleted codes.

CPT 2006 also deleted all of the "Supply of Materials" codes (92390-92396), covering the supply of spectacles, contact lenses, low-vision aids and ocular prostheses. Revised instructions in the "Contact Lens Services" section read, "The supply of contact lenses may be reported as part of the service of fitting. It may also be reported separately by using the appropriate supply codes." Keep this list handy:

• 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

• 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

• 92325 -- Modification of contact lens (separate procedure), with medical supervision of adaptation|

• 92326 -- Replacement of contact lens.

Add modifier 52 (Reduced services) for prescription and fitting of one eye (for example, 92310-52)

For therapeutic or surgical use of contact lens, see 68340 (Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens), 92070 (Fitting of contact lens for treatment of disease, including supply of lens)

You should report follow-up of successfully fitted extended wear lenses as part of a general ophthalmological service (92012, Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient)

Watch for Underpayment for Lens Services

For example: When fitting a keratoconus patient with a new type of contact lens, report 92310 for the contact lens services and an appropriate code from the V2500-V2599 series (Contact lens ...) for the supplies.

Caution: Carriers often underpay 92070 for what the physician does because of the wide price variability for a contact lens.

Many offices provide lenses ranging in price from less than $45 to more than $180 each. Yet there are only limited CPT codes to cover contacts. One code cannot cover such a wide range of products, so try to bill services and materials separately. Even then, the HCPCS V codes cannot accurately describe the reasons and costs involved with some of the newer materials.

Try to find out what the insurance company will allow and then explain to the patient what his options are. Let your patient decide whether you will provide only what the insurance company will allow, or do what is best for your patient and let him pay the difference.

Untangle DMERC Rules

When a patient comes to your office after cataract surgery, he's probably going to need refractive lenses. And if you want reimbursement, you're going to need to unravel your durable medical equipment regional carrier's (DMERC's) complex coding and billing rules.

Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal -- for example, after cataract surgery or congenital absence). Medicare covers one pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens. You must link your DMERC claim for refractive lenses to one of these ICD-9 codes to prove medical necessity:

• 379.31 -- Aphakia

• 743.35 -- Congenital aphakia

• V43.1 -- Organ or tissue replaced by other means; lens (pseudophakia).

Append KX for Doctor-Ordered Extras

The key to DMERC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code.

The prescribing physician must specifically order the special lens; the patient's preference for one type of lens over another is not enough. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity for the item you're claiming.

Example: In most cases, Medicare will not pay for polycarbonate lenses (V2784). Patients often prefer polycarbonate lenses because they are sturdier and lighter than regular lenses. Many physicians prescribe polycarbonate lenses for patients with monocular vision, however, to help protect the remaining eye.

In these cases, report V2784-KX and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, "best corrected VA OS 20/400" should suffice.

Additionally, Medicare considers ultraviolet protection (V2755, U-V lens, per lens) reasonable and necessary after a cataract extraction. But you can only claim V2755 if the UV coating is applied to a glass or plastic lens. If UV protection is inherent in the lens material (as with polycarbonate lenses), you cannot report V2755 as an add-on code.

Along with V2755 and V2784, Medicare will sometimes pay for the following items, if they are medically necessary:

• Tints (V2744, V2745)

• Anti-reflective coating (V2750)

• Oversize lenses (V2780).

Use EY for Patient Preferences

What if the prescribing physician did not specifically order an item, but the patient wants it anyway? Append modifier EY (No physician or other licensed healthcare provider order for this item or service) to patient-preference items. EY is the opposite of KX, and you should use it on items that are sometimes medically necessary and sometimes not.
 
Append modifier EY to V2744, V2745, V2750, V2780 and V2784 if the patient selects them without a specific order from the prescribing physician.

Although individual rules may vary, do not expect coverage from your DMERC carrier for the following:

• Deluxe frame (V2025)

• Deluxe lens feature (V2702)

• Eyeglass case (V2756)

• Scratch-resistant coating, per lens (V2760)

• Mirror coating, any type, solid, gradient or equal, any lens material, per lens (V2761)

• Polarization, any lens material, per lens (V2762)

• Progressive lens, per lens (V2781)

• Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens (V2782)

• Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens (V2783).

You may also need to append modifiers LT (Left side) and RT (Right side). If you're providing the same kind of lens on both sides, bill both on the same line of the claim form, append both LT and RT, and claim two units of service.

Example: Medicare will pay for trifocal lenses (V2300, Sphere, trifocal, plano to plus or minus 4.00d, per lens), but the patient wants antireflective coating (V2750) as well.

On the claim form, report:

• V2300-RT-LT with two units of service

• V2750-RT-LT-EY with two units of service.

Tip: Most electronic claims can't handle four modifiers. If this is the case, omit EY.

Report contact lens supplies for aphakic patients using the HCPCS V codes (for example, V2510, Contact lens, gas permeable, spherical, per lens; or V2522, Contact lens, hydrophilic, bifocal, per lens). Append modifiers RT and LT for each eye and modifier KX to indicate medical necessity.

Don't code separately for lenses for keratoconic patients. For the fitting, report 92070. Because 92070 specifies that supplies are included, do not code separately for them.

Example: For the fitting of one aphakic lens, 92311 has a bilateral status of "0," and you therefore may never append it with modifier 50 (Bilateral procedure) on a claim form. To report aphakic lens fitting for both eyes, use 92312.