Wiki Appending Modifier 22 to 92310 / Contact Lens Fittings

[alix.orozco@gmail.com]

I'm currently studying for CPC certification and I recently started working for an optometrist. Today, we went over commonly used CPT codes for patient billing and claim filing.

In an effort to apply my knowledge/training to my work, I am trying to understand definitions/rationales for the codes I was given. When I got home, I cross-referenced everything with the 2019 CPT codebook.

The codes I was given for contact lens fittings are as follows:

- 92310 for single vision fitting
- 92310-21 for toric fitting
- 92310-22 for multifocal fitting

The first thing that confused me was the use of modifier 21. I couldn't find it in Appendix A of the CPT and after a little bit of digging (by which I mean Googling), I found that modifier 21 was deleted and obsolete as of 2009. I was able to find the definition for the now defunct modifier 21 (Prolonged E/M Services). My next thought was that modifier 22 would be appropriate since it denotes Increased Procedural Services.

In my research, I found nothing supporting the use of modifier 22 to file claims for specialty contact lens fittings. In fact, based on my reading, I'm inclined to believe that 92310 would cover all fittings that would not meet the definitions of 92311-92317.

I do know that our practice charges higher rates for fitting toric and multifocal contact lenses, which would make the use of modifier 22 logically sound for someone who isn't a coder. (Additionally, nobody in our office is trained or certified specifically for coding. Almost all of the codes are given by the doctor.) When I do start filing claims, I want to make sure I'm coding accurately (and bring attention to potentially erroneous coding practices).

So to summarize my inquiry, should specialty contact lens fittings be coded differently than single vision? And if so, should I be using modifier 22 or something else? Why or why not?

(This also raises a billing question, if anyone is well-versed. If I should be using modifier 22, how do I put this into Item 19 on the CMS 1500 form (format of entry/qualifiers, what sort of additional documentation would support this)?

 

[Cheezum51]

I'll answer your question from a practical standpoint as an optometrist who was in practice for 40 years and fit lots of contacts.

First of all, don't use the 22 modifier on the 92310 code. It really won't mean anything to the insurers as the how to value the fitting fees for the various types of contact lenses.

That being said, I'm not aware of any insurer that will pay for the fitting of cosmetic contact lenses, which is what you've asked about. Many will pay for medically necessary contacts such as for patients with keratoconus but you need preauthorizations for those services.

The vision care plans, such as VSP and EyeMed, usually have an allowance to pay for the fitting of cosmetic contacts. As an example, if VSP allows $150 for CL services and your fee for spherical CL fittings is $100, you bill that. If it's $150, then you bill them that. Most don't require you to specify the type of lenses you fit.

We used the 92310 fitting code and assigned internal modifiers to it for the various types of cosmetic lens fittings so our practice management software would know what amount to bill out for the various services. We didn't use those modifiers when billing the vision plans, because they wouldn't mean anything to them.

I hope this helps.

Tom Cheezum, O.D., CPC, COPC

 

[alix.orozco@gmail.com]

Hi Dr. Cheezum,

Thank you for taking the time to respond to my question. It's clear now that I was over-thinking since they were, as you described, internal modifiers for the software. I wish it was explained to me that way when I was given a list of reference codes.

That being said, I had my first experience filing vision claims on Monday. It seems like the majority of them are questionnaires that auto-populate the form with the corresponding codes. (After practicing CMS 1500 forms ad nauseam in school, I was shocked.) A good reminder that coding and billing are different things.

In either case, I appreciate understanding the logic behind what I'm doing instead of blindly copying. Thank you again!

 

[Cheezum51]

What you have to understand is that, excuse my language, the vision care plans have bastardized the CPT coding system for their own purposes. In reality, instead of them utilizing the E/M or 92xxx optometry/ophthalmology codes for billing purposes, they should be using the "S" codes which are geared more for the "wellness" type exams these plans pay for at their paltry reimbursement rates.

As you learn how to do eye care related billing and coding, you will, as it seems you have begun to do already, realize that you will have to learn two coding systems. One for the medical eye care claims and one for the vision care discount plans.

Good luck as you progress in your career.

Tom Cheezum, O.D., CPC, COPC