The Business of Contact Lenses

A Review of the Contact Lens Prescribing Codes

BY CLARKE D. NEWMAN, OD, FAAO

I receive questions on a daily basis about how to bill for medically necessary contact lenses. Most of the questions that I receive reflect the changing reality of specialty lens prescribing for diseased, disfigured, and transplanted corneas.

The hard cold reality is that the Current Procedural Terminology (CPT) contact lens prescribing codes are completely antiquated and do not reflect the range of lenses that we prescribe today for patients needing medically necessary contact lenses. As a result, there is very little uniformity among the payers regarding how to code and bill for these services.

Overview of the 9231x Codes

Besides the codes for keratoconus and bandage lenses, there are, essentially, four CPT prescribing codes for medically necessary contact lenses. These are the 9231x codes, which differ from the newer 92071 and 92072 codes that I discussed in my April column.

The 9231x codes all include a provision contained in a pre-text preamble, which states that the fee includes the diagnostic determination of the lens parameters, the dispensing of the lenses, and the instruction and training of the wearer. It also covers “incidental revision during the training period.” None of that is defined.

I think the training period is similar to the “adaptation period” referenced in the code texts. A defensible and rational definition of adaptation period is the time that it takes for a patient to achieve the prescribed wearing time.

Further, I think a defensible and rational definition of “incidental revision” is a change that can be made to an existing lens in hand. If another lens is required due to a design or a material change, then that is beyond an “incidental revision” and, therefore, warrants another billing of a 9231x code.

Understanding the Code Texts

Now, let’s review the code texts. The 92310 code text reads, “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation, corneal lens, both eyes, except for aphakia.” So, this code covers the prescribing of the lens and the follow up through the time that it takes for the patient to adapt. After that, the preamble text says to bill other general ophthalmological service codes for follow up services.

As always, these codes are not “fitting fees” meant to cover all services. The ophthalmological examination of a patient and all ancillary testing that is rational to determine the best correction for the patient are not covered by the 9231x codes.

The other 9231x codes contain the same code text except for the type of lens and whether it is for one or both eyes. The 92311 code is for a corneal lens for aphakia, one eye, while the 92312 code is for corneal lenses for aphakia, both eyes. The 92313 code is for a corneoscleral lens. Because the text is singular in this code, it implies that you should bill this code for each eye if the prescription is bilateral, and it should be amended with the appropriate –RT and –LT modifiers. This code follows the bilateral exemption—so, you get paid 100% for each eye.

The 92314 to 92317 codes mirror these codes for non-physician prescribers.

When None of These Fit

Finally, you can use 92499, the unlisted ophthalmological service code, for a contact lens that does not fit any of these categories. However, a letter of medical necessity is needed and an adjudication process will follow. CLS

Dr. Newman has been in private practice in Dallas 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, AMO, and Alden Optical. Contact him at cdnewman@earthlink.net.