Optometry Coding & Billing Alert

Clear the air on appropriate codes to boost practice revenue

Getting insurance claims paid for prescriptive medical devices such as contact lenses can be tricky. Insurance carriers aren't quick to reimburse for these. It makes your job a little harder, but that doesn't mean that you should give up your reimbursement rights.

By avoiding a few common errors, you can ensure that your contact lens claims reap rewards. Here is a quick guide to help you avoid the common pitfalls that you may encounter while filing a contact lens claim.

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

Example: For most patients, "you should bill the initial fitting with code 92310," says Regan Bode, CPC, CPC-H, CPC-E/M, ACS-EM, PCS, OCS, product manager for Custom Coding Books LLC.

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.

If a tech -- not an optometrist -- provides the contact lens services, look to the following codes:

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," says Becky Zellmer, CPC, MBS, CBCS, provider educator for Prevea Clinic in Green Bay, Wis.

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

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

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.

Tip: "Most insurance contracts do not limit the amount you can charge for your supplies, they only limit the amount the patient has covered. If the insurance only covers a set dollar amount, the remainder of the charges should be patient responsibility, not a write-off," Bode says.

"If the patient is seen back for a follow-up, you would bill the appropriate office visit for the encounter," Bode says.

So, 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).

Fitting: "For fitting, the optometrist needs to document the proper measurements for correct contact lens fitting, and document their findings for base curve, diameter" and power of the lens, Bode says.

As a cautious approach, 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).

Follow-up: "Follow-up visits should document the fit of the lens along with the correct vision findings," Bode says.