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Optometry Coding & Billing Alert

Not Getting Paid for Contact Prescriptions? You Will After You Read This

Published on Thu May 06, 2004

92310 won't cut it - but 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 optometrist 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, since 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 non-inflammatory, self-limiting ectasia of the axial portion of the cornea ... characterized by progressive thinning and steepening of the central cornea," according to the Center for Keratoconus at www.kcenter.org. For mild cases of keratoconus, glasses may adequately correct the patient's vision. More severe cases of keratoconus may require hard or gas-permeable contact lenses.

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 medicare 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 with 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 invoice to substantiate the cost of the lens.

For the actual billing of the lens, use 92070-22 (Unusual procedural services). Reporting a service with modifier -22 along with documentation automatically routes the claim for review and special pricing. Submit these claims by paper so the carrier is sure to keep your documentation with your claim.

Caution: You may get into some sticky split-billing situations when you insert a BCL during a patient's postoperative period for cataract or corneal surgery. The problem with billing for the service, if the patient has Medicare, is that a global surgical package applies that  includes "All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room." If the optometrist places the lens in the patient lane, which is not an operating-room setting, you cannot report 92070 because carriers include it in the postoperative package of corneal and cataract surgery.

Stay Away From 92310 for Aphakia

Situation: A patient doesn't have her own natural lens (aphakia, 379.31 or 743.35). The optometrist fits a contact lens for refractive error correction. You can't use 92310 in this case -- it says so right in the code description. Which  code should you report?

Solution: Choose from the following codes that represent the prescription of contact lenses for aphakia:

  • Prescription for one eye: 92311 -- Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye
  • Prescription for both eyes: 92312 -- ... corneal lens for aphakia, both eyes
  • Prescription for corneoscleral lens: 92313 -- ... corneoscleral lens.

    Medicare will pay for contact lens fitting and supply for patients with aphakia. If the optometrist writes the prescription for an aphakia patient, but a technician who is an independent contractor in your office does the actual fitting, code one of the following:

  • Prescription for one eye: 92315 -- Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, one eye
  • Prescription for both eyes: 92316 -- ... corneal lens for aphakia, both eyes
  • Prescription for corneoscleral lens: 92317 -- ... corneoscleral lens.

    Beware: Most Medicare carriers have established guidelines for how often they will replace a contact lens for an aphakic patient, Arendt says. "One claim per year or every couple of years" per aphakic eye is what carriers expect to receive, she says. Medicare may deny or suspend the claim and request additional information before processing.

    That's true, says Amy S. McCreight, CPC, compliance research analyst for Ohio Health -- but she adds that it's possible to get reimbursed more often than once every two years if you have the proper documentation. "If you show medical necessity for the lenses, they will pay for them more frequently," she says. McCreight recommends sending a letter from the doctor explaining why the patient needs new lenses more often.

    For supplies: Bill your DMERC for the lenses themselves using the HCPCS V25xx codes (for example, V2510, Contact lens, gas permeable, spherical, per lens; or V2522, Contact lens, hydrophilic, bifocal, per lens), adding the -RT and -LT modifiers for each eye and modifier -KX (Specific required documentation on file) to indicate medical necessity, Arendt says. Include the date of the original surgery and the diagnosis code.

    Arendt recommends the more specific V25xx codes instead of 92070, which does not specify the type of lens prescribed. "They want to know what kind of lens," she says, "so you should use the HCPCS code and be more specific."

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