coding strategies

Revisiting Coding for Medically Necessary Contact Lenses

BY CLARKE D. NEWMAN, OD, FAAO

Mea maxima culpa! Since I began writing these articles in January 2008, by far the most questions I have received concern a topic that, apparently, I did not cover in-depth enough the first time.

I am referring to the CPT codes for prescribing medically necessary contact lenses. These codes are commonly referred to as the "9231x" codes. They are:

Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation;

• 92310 — corneal lens, both eyes, except for aphakia
• 92311 — corneal lens for aphakia, one eye
• 92312 — corneal lens for aphakia, both eyes
• 92313 — corneoscleral lens

Using the 9231x Codes

Use the 92310 code whenever you prescribe a lens that rests solely on the cornea. It is a "bilateral" code that is billed one time whether you are prescribing for one or both eyes.

For aphakic patients, bill either the 92311 or 92312 codes depending upon whether you are prescribing for one or both eyes, respectively. Again, these codes are restricted to "corneal" lenses.

If you are prescribing a lens that covers the cornea and the corneo-scleral area, then use the 92313 code. This is a "unilateral" code that you must bill twice if you prescribe for both eyes. You will want to use the "reduced service (−52) modifier" on the second eye and the "RT" and "LT" to show the insurance company that you are not double billing for the same service. Finally, the 92310 code is not limited to rigid lenses, so if a soft corneal lens were ever developed, it could be coded as such.

The 92314-92317 codes are mirrors of the 92310-92313 codes except that they are used when an "independent" technician is "fitting" the contact lenses instead of a "physician" (that would be us) or a technician under the direct supervision of the prescribing practitioner.

Further, CPT makes the following clarifying remarks regarding these codes: "The prescription of contact lenses includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, gaspermeability). It is NOT a part of the general ophthalmological services. The fitting of a contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period. Follow-Up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service. (92012 et seq) The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code."

Bill for the examination and all of the extra testing separately.

These codes are not fitting fees! They are not intended to cover all of the services in prescribing a lens to a patient — they are intended to cover the prescribing, dispensing, and the initial monitoring of adaptation. In my opinion, they get you through the first follow-up visit. If you make anything that is not an "incidental change," then you bill the code again. The term, "incidental" is not defined. I have defined it as changing the lens type or changing something significant — such as the lens diameter.

Next Steps

After the unspecified "adaptation period," begin billing the E/M codes or the general ophthalmological codes because you are evaluating the patient's medical condition in the presence of the contact lenses. I use the general ophthalmological codes because the CPT information specifically says that you should. 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. He is also a consultant or advisor to B&L.