Ophthalmology and Optometry Coding Alert

92310 won't cut it - this strategy for keratoconus and aphakia patients will You know you can't bill Medicare for regular refractive contact lenses, but you can expect reimbursement for contact lenses for patients presenting with keratoconus and aphakia - if you know these expert rules of the road. Prove Medical Necessity for Keratoconus Patients Situation: A 16-year-old patient presents with distorted and blurred vision along with glare and light sensitivity. The ophthalmologist diagnoses keratoconus (371.60-371.62) 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 right because the patient's carrier considers it to be a refractive-error correction. Is there a more specific code you can use to describe the procedure?

Solution: To avoid denials when prescribing a contact lens to treat keratoconus, use 92070 (Fitting of contact lens for treatment of disease, including supply of lens), says Brenda Arendt, CMC, of the Center for Total Eye Care in Westminster, Md. Keratoconus is a disease in which "the central or paracentral cornea undergoes progressive thinning and bulging, so that the cornea takes on the shape of a cone," according to the American Academy of Ophthalmology. "Some cases of keratoconus are sufficiently mild, at least for a time, for the vision to be corrected adequately with glasses. However, hard or gas-permeable contact lenses are far more helpful in all but the mildest cases."

Supplies: The kind of contact lens used to treat keratoconus is a "bandage contact lens (BCL)." Using 92070 in a patient with keratoconus shows that the lens is for treatment of a medical condition, not a refractive condition. And since the code specifies that it includes the supply of the lens, your regular Medicare carrier will reimburse you for the supply of the lens as part of the procedure fee - so you shouldn't separately report the lens to a durable medical equipment regional carrier (DMERC), Arendt says.

Documentation: Years ago, you could bill both the service and the lens to Medicare, but this changed after Medicare conferred with a consultant who stated that the majority of the time an inexpensive, soft contact lens was used for the service. If your doctor was unsuccessful using a soft lens to treat a disease and must use the more expensive hard or gas-permeable lens, you can attempt to bill your carrier for the expense. To receive payment, you will need to send a brief explanation detailing why the doctor used the hard lens, along with chart documentation of the failed attempts at using a soft contact lens. You will also need to provide an [...]