The Business of Contact Lenses

Billing for Examining Medically Necessary Contact Lens Patients

BY CLARKE D. NEWMAN, OD, FAAO

In June, I began again to discuss the process of coding and billing for medically necessary contact lenses. My last two columns went over the coding and billing for Vision Service Plan (VSP) and EyeMed. Now, back to business.

Investigate Plan Specifics

After deciding which insurance panels make economic sense for your practice and getting credentialed on those plans, the next step is to research what those plans do and do not cover regarding medically necessary lenses.

Before a patient comes in—let me say that again—before a patient comes in, your staff should get the patient's health insurance and vision insurance information, then determine what benefits he has in this area. Whether or not the patient's insurance covers medically necessary prescribing can then be discussed before you do any prescribing.

Conduct a Thorough Exam

Before the diagnostic lens evaluation, however, the standard of care—particularly with a new patient to your practice—is to examine the patient. With many of the conditions that necessitate medically necessary lenses, a complex and detailed history and a thorough review of systems is necessary. This complex review is part of the reason why we use the higher Evaluation and Management (E/M) Levels. While patients may walk in the door with a diagnosis, it is your responsibility to new patients to confirm that diagnosis before you select an appropriate management plan.

Even if a new patient's entering diagnosis is correct, the level of severity and the presentation of any defect that degrades visual performance are unique to that patient. The medical decisionmaking may be complex for new patients, and it may be affected by information that you do not have when patients initially present to your clinic.

For existing patients, the diagnosis is already established, and higher E/M Levels may not be appropriate. However, many conditions that we manage in this area are progressive, and they may require a re-evaluation to determine how much change has occurred and how that change will affect your medical decisionmaking. Examples include monitoring grafts and ectasia. In such cases, use your best judgment. Both up-coding and down-coding are frowned upon equally, and we are guilty of both. I encourage all of you to read the time and complexity requirements for the various E/M Service Code Levels. Not only will that knowledge help you select the appropriate code for examining medically necessary contact lens patients, but every other patient as well.

When performing additional testing, if the test is rational to the diagnostic process and the results will alter your medical decision-making, then those tests are medically necessary as long as they are ordered, have a defined indication, are interpreted, and the change to medical decisionmaking is documented.

Coding Right is Good Business

Correct coding is the duty of all prescribers. It is also a best practice for reducing billing errors and rejections. Nothing is more efficient and defensible than doing things right the first time. While that may not keep the auditors away from your door, it may make that process less painful and expensive.

Finally, organized and complete record keeping is important in demonstrating to auditors that covered services for which you bill the carrier meet the definition of necessity, and are thus payable under your contract. 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 a Diplomate in the AAO and a consultant to B+L and AMO. Contact him at cdnewman@earthlink. net.