coding strategies

The Liquid Bandage Lens

BY CLARKE D. NEWMAN, OD, FAAO

Once again, I thought we'd rummage through our "junk drawer" to see if there are any other gems. As I look around, I see that we have not taken the HCPCS S0515 code out for awhile.

This code was added to CPT Part II in 2004 to describe use of a GP scleral lens as a liquid reservoir to act as a "liquid bandage" for a severely dry eye. This lens type is used in a patient who has extreme "exposure keratitis" (cannot close the lid) or after a severe burn, or in a patient with ocular pemphigoid, for example.

CMS National Carrier Determination (NCD) policy 80.5 — Scleral Shell states:

"Scleral shell (or shield) is a catchall term for different types of hard scleral contact lenses. A scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens which covers only the central non-white area encompassing the pupil and iris. Where an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding orbital tissue. In such a case, the device serves essentially as an artificial eye. In this situation, payment may be made for a scleral shell under §1861(s)(8) of the Act."

Billing for Scleral Shells

Scleral shells are occasionally used in combination with artificial tears to treat "dry eye" of diverse etiology. Tears ordinarily dry at a rapid rate and are continually replaced by the lacrimal gland. When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by using a scleral contact lens as a protective barrier against the drying action of the atmosphere. Thus, patients can avoid the difficult and sometimes hazardous process of frequent artificial tear use.

The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal gland and would be covered as a prosthetic device in the rare case when it is used in the treatment of "dry eye."

The Berrenson-Eggers Type of Service is "unclassified" for HCPCS S0515. Further, CMS has deemed it a "Non-Covered Service." Therefore, there is no established fee schedule for it. Because there is no established fee schedule for the S0515, you are free to charge what you believe is appropriate. Because the S0515 code is a "non-covered" material code, I never use it. Instead, I use the HCPCS V2627 code. That is why we never take the S0515 out of the junk drawer.

When we fit scleral shells in our office, we bill the services appropriately as a CPT 92313 (Prescription of optical and physical characteristics of and fitting of contact lens with medical supervision of adaptation; corneoscleral lens). We bill each lens as either V2531 (Contact lens, scleral, GP, per lens) when the goal is to restore vision, or as V2627 (Scleral cover shell) when we are using the lens as a liquid bandage.

The reimbursement for the V2627, depending on the insurance plan and the locale, varies between $1,075.21 for Texas Medicaid — the lowest reimbursement for this service and material — to a high of around $2,000 per lens for New York City private insurance carriers.

Worth a Look

It pays to rummage around in the junk drawer. I'll bet most of you thought you could bill Medicare only for aphakia, but Medicare will pay for contact lenses for dry eye as well. 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.