The Business of Contact Lenses

Understanding the New 92071 and 92072 Codes

By Clarke D. Newman, OD, FAAO

On Jan. 1, CPT “bandage lens” code 92070 was deleted. Its descriptor was, “Fitting of contact lens for the treatment of disease, including supply of lens.” This code wasn't subject to the bilateral rules, which state, “The usual payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier –50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules.”

Ocular Surface Disease Codes

The first of the two new contact lens prescribing codes is the 92071. The descriptor for this is, “Fitting of contact lens for the treatment of ocular surface disease.” Note that the supply of the lens is not part of this code.

There are two instructions with this code. First, we have the prohibition of using the 92071 and 92072 code at the same visit.

Second, we have a direction on billing for materials, which states, “Report supply of lens separately with 99070 or appropriate supply code.” The descriptor for CPT Code 99070 states, “Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).”

The Relative Value Unit (RVU) for the 92071 is significantly lower than that of the 92070. This change owes to the contemplation of reimbursement for the lens supply elsewhere. It is important to use both the 92071 and the 99070, each with the proper “RT” or “LT” designation, so you get full reimbursement for services and materials.

Previously, because they were bundled, Centers for Medicare/Medicaid Services (CMS) paid for the whole thing. What remains to be seen is whether CMS rules this “single-use product” as Durable Medical Equipment (DME), thus requiring the billing to the appropriate Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS). There is precedent for single-use products not being qualified as DME. To my knowledge, there has been no ruling on this yet.

Finally, the NCD 80.1 describing the intent of what is a bandage contact lens is still in force, and the bilateral exclusion applies to 92071 just as it did to 92070. It also applies to the new 92072 code. So, you bill it twice if you do both eyes. Code them RT and LT to prevent the assumption of duplication, and you will get the full fee for each eye.

Keratoconus Lens Coding

The second new code is CPT 92072. The descriptor is, “Fitting of contact lens for management of keratoconus, initial fitting.” This code replaces the use of a 9231x code for keratoconus. It must have an accompanying diagnosis code of keratoconus, and it is only for the first lens.

The preamble for the 9231x codes doesn't apply, and subsequent fittings and follow ups are billed using E/M codes or the general ophthalmological codes. The lens is reported using the 99070 just as with the 92071. The 92072 is now a covered service under Medicare. Remember to follow the instructions for subsequent billings, as this code is for the first lens per eye only. CLS