coding strategies

Myths, Lies and Other Unprofitable Thinking

BY CLARKE D. NEWMAN, OD, FAAO

To paraphrase Lord Byron, a lie is but the truth in masquerade. This observation is especially true when it comes to medical billing. You have to search for the truth through all of the information that passes as practice management advice. I caution you to cast a jaundiced eye towards everything you read and hear related to medical billing and practice management — including everything that I tell you.

With that little mind vitamin in hand, let's look at a few myths and lies that are holding us back from reaching our profit potential.

Medically Necessary Lenses

The first myth that has festered into a fact dovetails with my February column. I can't tell you how many times I've heard practitioners say that a patient has to be uncorrectable to 20/20 with glasses before a contact lens prescription is medically necessary. Wrong! If you don't understand this concept, go back to my February column and re-read the definition of medical necessity.

A contact lens prescription rises to the level of medical necessity in many cases that have nothing to do with acuity, such as when prescribing a scleral lens for a severely dry eye.

Letters of Medical Necessity

The second lie that keeps getting in the way is the belief that letters of medical necessity (LMN) are required only when you use the unlisted ophthalmological code. While an LMN should always accompany the use of the unlisted code (used mainly for aberrometry), in many other cases an LMN will grease the skids of the payment process. An LMN is very helpful whenever you use one of the contact lens fitting codes (9231x).

Insurance companies are very resistant to the concept of medically necessary contact lenses. An overwhelming majority of the time, they just don't get the therapeutic nature of what — to them — is an elective, cosmetic trifle. An LMN helps clear their fuzzy thinking.

You should use an LMN whenever billing for anything that might not seem rational upon first blush. We will discuss these letters more in depth in a future column.

Fitting Codes vs. Service Fees

Finally, the biggest myth of all is that the 9231x contact lens fitting codes are basically fitting fees. Essentially, these fees cover only the diagnostic evaluation of a new informalens design and the adaptive period, which is usually just the first follow-up visit. For first-time wearers I use what I call an "Initial Dispensing Fee" that closely follows the CPT definition of the 9231x codes.

Prescribers lump an endless array of services under a fee that is higher than it should be for the simple cases and too low for the complicated ones. I hear practitioners gripe all of the time that you can't make any money using the 9231x codes — the reimbursements are just too low. They're right if they think that fee covers all of their contact lens professional services. That's just crazy!

When you realize that you can charge one of these fees again if you change a patient to a different lens, and that you can charge service fees for follow-up visits, you free your mind for more profitable thinking.

Get Your Facts Straight

The bottom line is that knowing what isn't true is a good thing. So, let's fact check all of the snake oil advice that people like me try to sell. And at the end of the day, we will make more money and we will help more people see well.

Next month, we'll tackle how to get through contracts. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery.