MANAGED CARE
Playing the Insurance Game
You can best serve your patients and make the most profit for your practice by using the right billing codes.
By Michael Greenberg, OD, MS, FAAO

A wide variety of health, medical and vision care insurance plans have evolved over the last 15-to-20 years. We're all familiar with the alphabet soup of medical plans: Preferred provider organizations (PPOs), health maintenance organizations (HMOs), managed care plans (MCPs), etc. Each of these programs, including Medicare, may incorporate eyecare services depending on the individual plan's provider policy. I'll help you sort through all the vision care coding and billing red tape so you can better serve your patients and receive appropriate compensation.

Think Like a Doctor

To succeed in the managed care arena while fitting, dispensing and evaluating contact lenses, you must think of yourself as more than just a refractionist and provider of contact lenses and eyeglasses. Rather, think of yourself as the family eye doctor, which may require a change in your personal attitude. An eye doctor must always strive to evaluate the patient's eye and vision from a medical point of view. Think about whether a medical diagnosis is appropriate for each patient visit. If you, as the eye doctor, ask enough questions while performing the patient history and examine the eye from a medical point of view, then you may find a medical diagnosis that will allow you to bill the visit to medical insurance.

Contact Lens Coverage

Medical plans vary as to the inclusion or exclusion of contact lenses. Usually, a medical plan will cover the fitting and dispensing of contact lenses if a patient requires them for functional vision, such as for patients who have aphakia or keratoconus.

If a patient uses contact lenses to correct normal vision abnormalities such as myopia, hyperopia, astigmatism or presbyopia, then the patient must have a vision care rider within his medical plan to receive coverage. Another option is to have a separate vision care plan, such as Vision Service Plan (VSP), that would provide an allowance toward the fitting and dispensing of contact lenses.

Vision care plans or vision care riders provide a set allowance toward the total cost of cosmetic contact lenses and their related services. Each carrier provides unique allowances for each of their respective plans, and you must make yourself aware of the allowance for each plan by verifying it with the appropriate insurance company.

The total cost of contact lenses includes their initial fitting and evaluation as well as their material costs. Don't forget about contact lens follow-up evaluation fees for returning patients. For example, suppose that you fit a myopic patient with contact lenses for the first time. Your complete fee should include the fitting and follow-up evaluation of the contact lenses plus the material cost. Let's say this amounts to $200. If the vision care plan offers a $120 allowance toward contact lenses, the patient would owe $80 out-of-pocket for charges that the plan doesn't cover.

In the case of a contact lens wearer who returns for a yearly eye examination and requires replacement contact lenses, you are entitled to charge for the eye examination as well as for a contact lens progress evaluation to determine the condition of the contact lenses and the health of the eye. This is in addition to contact lens material costs. The vision plan would cover the eye examination itself, and you would subtract any contact lens allowance from the total contact lens-related service and material charges. For example, if your total contact lens service and material charges are $150 and the vision care plan has an allowance of $120, then you should charge the patient the $30 difference.

Speaking in Code

To select the proper codes for billing, you must first become familiar with coding principles as well as CPT and diagnosis codes. Codes for Optometry is available from the American Optometric Association and is a good source. Also, several pharmaceutical companies including Alcon and Pfizer offer pocket coders.

Vision Care Plans To bill a vision care plan, you must know the specific codes and policies of each carrier. The codes and policies vary from plan to plan, but usually you'll bill for the fitting and evaluation using the CPT code 92310 and material "v" codes, as listed in Codes for Optometry. Keep in mind that 92310 has the definition: "prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia." My interpretation of 92310 is that you should use it only for the initial fitting and evaluation of new contact lenses and not for contact lens progress evaluations. To my knowledge, a specific contact lens progress evaluation code doesn't exist, but you may still charge a fee for this service. Some plans may want the material and evaluation fees totaled together. Checking the provider manual or placing a call to provider relations will answer such questions.

Medicare and Contact Lenses Medicare covers contact lenses only for aphakic patients or those who suffer from a corneal disease such as keratoconus. Medicare requires that you bill the contact lens services and materials separately. In the case of aphakia, use 92311 if you fit one eye and 92312 if you fit both eyes. These codes have the definition: "prescription of optical and physical characteristics of and fitting of contact lens with medical supervision of adaptation, corneal lens for aphakia, one or both eyes." If you fit a corneal scleral lens, use 92313.

Bill appropriate "v" material codes using corresponding modifiers — "LT" (left eye), "RT" (right eye) and "50" (both eyes) — for aphakic patients.

Use the 92070 code for corneal disease patients who need a bandage lens. This is a unilateral code, so you must also use the modifiers "LT" and "RT" in conjunction with this code. Code 92070 has the definition: "fitting of contact lens for treatment of disease, including supply of lens." In such cases, your Medicare carrier will reimburse you for the material cost of the contact lens as part of the procedure fee. Don't separately bill the material fee using a "v" code with procedure code 92070.

Be aware that Medicare's reimbursement for 92070 under the Medicare Fee Schedule is somewhat low based on the assumption that you'll dispense a soft lens with this procedure.

Most keratoconus patients require a more costly GP contact lens. In this case, bill the carrier for the use of the GP lens. An accompanying written explanation as to why a you need to fit a GP contact lens is necessary to receive proper reimbursement from Medicare.

Medical Necessity As with Medicare, medical insurance will usually cover contact lenses to provide vision improvement in cases of corneal disease. Keratoconus and irregular astigmatism are included in this category. Be aware that some insurance companies have rules stating that the corrected vision with eyeglasses must be 20/70 or worse before they will cover contact lenses. Consult with the insurance company's professional relations department to ascertain their rules. When you fit contact lenses on such patients, use the code 92310 along with the modifiers "RT" and "LT."

Topography In addition, if you use a topographer to help diagnose a corneal irregularity and to help fit a contact lens, then you can use the miscellaneous code 92499. When you use this code, an electronic claim may not be allowed. This situation varies by insurance company. If a written explanation is necessary, then you must include "corneal topography" in Box 24C of the HCFA 1500 form ("Fully describe procedures, medical services or supplies for each date given"). You must indicate the corresponding diagnosis, for example keratoconus (371.60-371.62) in the diagnosis field (Box 21 of the HCFA 1500 form) and again in the diagnosis code field (Box 24E).

Letter of Explanation The insurance company may also require an attached letter of explanation. The letter should state the patient's best-corrected acuity with eyeglasses and best-corrected acuity with contact lenses along with any other supporting information such as keratometry readings or a copy of the topography.

Cosmetic Contact Lenses

Cosmetic contact lens patients may also receive coverage from their medical insurance company for their office visit. Again, think of yourself as the family eye doctor, not just a vision care specialist. Be thorough in your case history and examination. What's the real reason for the patient's visit? Is it just a vision complaint or does a medical reason exist? Does the patient get headaches frequently? Does he have floaters? Does the patient have a medical condition requiring ocular evaluation? For example, most medical carriers in my area will cover a dilated eye examination if the patient has been diagnosed with diabetes.

If during the course of the patient's eye and vision examination you find a medical condition that requires further evaluation, have the patient return for a more thorough work-up. If possible, schedule the medical visit for a different day than the vision examination. For example, assume that during the course of the patient's vision examination you diagnose giant papillary conjunctivitis (GPC). If the patient reported for the examination asymptomatic, then he should return on a different day for evaluation and treatment of the condition. The patient's medical insurance would cover the second visit while vision insurance or the patient would cover the first visit. On the other hand, if the patient reports for the initial visit complaining of symptoms of itching and mucus discharge, then a medical reason and a diagnosis (GPC) exist, allowing you to bill the medical carrier for the visit.

Diagnosis of Exclusion

Remember, you can't bill medical carriers to "rule out." You must bill for symptoms. In the case of a patient who complains of floaters, for example, use the diagnosis Muscae Volitantes instead of retinal detachment. Other common symptoms that may allow you to bill the visit medically include visual disturbance (368.8) and pain in or around the eye (379.91). Medical carriers may not cover the visit if you use either of these diagnoses, but it leaves open the possibility if you do attempt to bill the medical insurance carrier.

Stay on Top

Changes will continue to occur in the insurance arena, some of them drastic. It�s our responsibility to stay informed. You and/or your insurance staff should read the insurance carriers� newsletters and check their Web sites on a regular basis. These habits will help you understand the managed care system, be aware of changes and, ultimately, to succeed when serving contact lens patients who have insurance coverage.