Ophthalmology and Optometry Coding Alert

Theres a perfectly good code for contact lens fitting for diseaseits 92070 (fitting of contact lens for treatment of disease, including supply of lens.) It should be obvious that the lens is not for vision correctionespecially when you add the appropriate diagnosis codes. But there are major problems getting these claims paid.

A particularly egregious problem is cited by Erica Gleason, billing administrator for Robert S. Haymond, MD, of Angels Camp, CA. In this case, the patient had a corneal ulcer, massive corneal abrasions, and contusions to the eyeball. The ophthalmologist used a corneal bandage, properly billing 92070. But the insurance companyan HMOdenied the charge. They said we need to bill it to the vision plan, says Gleason. Well, that obviously wasnt correct. So I appealed, but they denied it again. Ultimately, Gleason had to bill the vision plan. That isnt really fair, because then the plan bills the patient, she says. But what else can we do? I think they ignored the diagnoses and just saw contact, and decided, Ah, vision.

Submit Paper Claims Only

The carriers computer spits electronic claims with contact out automatically, explains Margaret Mac, CMM, CPC, of the Florida Eye Center in St. Petersburg, FL. Dont even try sending it electronically, because the payer will assume its for refraction, she says. I would send the claim in on paper right away. If you file electronically and need to appeal, the review could easily take two to three months, she explains. Why wait, when you can get reimbursed properly immediately.

With the claim, make sure you attach all the documentation, adds Mac. She uses photographs as well as notes; these can be dramatic in the case of corneal pathology or trauma.

Using Correct Diagnosis Codes is Key

There are different diagnosis codes that can be used to help justify payment for therapeutic contact lenses. For the hydrophilic, or soft, contact lenses, which are used as moist corneal bandages, here are some examples of covered corneal conditions, according to Mac:

371.23: bullous keratopathy (small blisters on swollen corneal epithelium)

375.15: tear film insufficiency, unspecified (eye
dryness and irritation from insufficient tear
production)

370.00-370.9: keratitis

371.20-371.24: corneal edema

371.72: descemetocele (protrusion of Descemets membrane into the cornea)

371.71: corneal ectasia (bulging protrusion of a thinned, scarred cornea)

371.52: anterior corneal dystrophies

For the RGP (rigid gas permeable) lens, you would
only use 371.60-371.62: keratoconus (bilateral [...]