The Business of Contact Lenses

Billing the Prescribing Codes, Part 1

BY Clarke D. Newman, OD, FAAO

Since I last addressed these procedure codes in Contact Lens Spectrum, a lot has changed. First, we have new Current Procedural Terminology (CPT) codes for keratoconus and bandage lenses—92072 and 92071, respectively. Second, there have been many changes to the Medicare Administrative Contractors (MACs) around the various jurisdictions, and that includes the Durable Medical Equipment (DME) MACs. These MACs have different carrier determination policies for some of these services.

Interpreting Codes

As with all CPT codes, interpreting what services are included, and thus, expected, when billing these codes is contained in a few areas. First is the text of the code. When looking at codes, the text following the code rules the day, unless modified by subtext instructions, as with the new 92071 and 92072 codes, or pretext instructions in a section preamble, as with the 9231x codes.

Second, there are interpretations that are contained either in CPT Assistant or in the Centers for Medicare & Medicaid Services (CMS) regulations and guidance, such as the “national carrier determinations” (NCDs). The NCDs for all of eye care are in Section 80 at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part1.pdf.

Of these policies, three are related to contact lenses. NCD 80.1 deals with bandage contact lenses, NCD 80.4 deals with the cosmetic exclusion, and NCD 80.5 deals with using lenses as a scleral shell. None of these policies have changed in recent years. So, if you have read them anytime in the recent past, then you know what is in them.

The 9231x Codes

When the diagnosis is not keratoconus, and the lens is not being used as a bandage, then the proper code to bill is the appropriate 9231x code.

The 92310 code deals with corneal GP lenses. It is a bilateral code for which the –52 reduced services modifier applies if you do one eye only. The 92311 and 92312 codes deal with prescribing for aphakia. If your diagnosis code is not aphakia, then you will get denied payment. The 92311 code is used when billing for one eye only. The 92312 is used when prescribing for both eyes. The 92313 code is for when prescribing a corneo-scleral lens. This code is not subject to the bilateral exclusion. So, if you prescribe for both eyes, then you would bill it twice using the –51 multiple procedures modifier. The first eye would be 92313-RT, and the second would be 92313-51-LT. Since the exclusion does not apply, you should get 100% of the maximum allowable charge for each.

The 9231x codes include the dispensing of the lens, incidental revision of the lens(es), and the follow-up services during the adaptation period. As I have said before, “incidental revision” and “adaptation period” are not defined anywhere that I can find. I have posited that a rational and defensible position is that an incidental revision is a change that can be made to the existing lens in hand. If you have to change it more than that, it becomes a major revision. Adaptation period, I think, is the time it takes to get to the prescribed wearing time.

The services provided to diagnose the disease, and the monitoring of the health of the eye in the presence of the lenses, are all billed separately with these codes once past the adaptation period. When medically necessary contact lenses are non-covered services, these service fees and the cost of the lenses are paid for by the patient. 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, AMO, and Alden Optical. Contact him at cdnewman@earthlink.net.