The Business of Contact Lenses

Medically Necessary Sanity

BY CLARKE D. NEWMAN, OD, FAAO

My last column laid out a concept for overhauling the medically necessary contact lens CPT codes. It had been rolling around in my pea brain for a long time. Let me explain some of what I believe.

What Needs to Be Fixed

I should begin by explaining why I think the current system is so flawed. By basing the service codes on the type of lens prescribed, we run into two problems. First, when a new technology comes along, the codes become constrictive. We would need a new code for every new technology, or prescribers would need to either shoehorn the new technology into some other code, or run the gauntlet of the unlisted codes.

The second problem with the current system is that it opens the list of possible diagnosis codes for each prescribing code to interpretation of medical necessity, further complicating the coding and billing for these services.

A condition-based coding schema would eliminate both of these real-world problems.

Second, much about what makes coding and billing for medically necessary lenses so difficult is that there are so many nebulous and undefined parameters contained in the plain language of the pre-texts, texts, and sub-texts of the codes. For example, the text of the current 9231x codes requires prescribers to bundle services for a time period that encompasses the “supervision of adaptation.” Nowhere is that defined, and confusion ensues.

Another example is found in the pre-text preamble of the 9231x codes. Contained therein is a reference to these services covering something that is termed the “incidental revision” of the lens. Again, this term is not defined, and it creates grey areas that prescribers must navigate. What constitutes an “incidental revision”? Should a second 9231x code be charged for the prescribing of a second lens that is more than an “incidental revision”? Again, confusion reigns.

A Step in the Right Direction

This problem of ambiguity was admitted when the American Medical Association (AMA) 92072 Editorial Committee created the 92072 code. In that code is an unambiguous sub-text instruction to use general ophthalmological or Evaluation/Management service codes for all subsequent visits. That was a huge step toward clarity. However, it created a new problem: coding and billing for keratoconus is now different in process and understanding from the other medically necessary lens prescribing codes. I have been asked more questions regarding these differences than most other things combined.

Also, the 92072 code contains the limitation “initial fitting.” What does that mean? Is it the first visit of a patient’s life? Is it the first visit of a patient to a particular prescriber? Or is it the first attempt at prescribing a new lens for a patient after that patient’s physical or optical characteristics have changed? I believe it to be the final option because that is the only one that seems to make any rational sense. However, a well-respected and highly qualified coding expert has said that it means “once per lifetime.” The difference in our interpretations comes from the fact that I prescribe these lenses for a living, which I believe gives me a better understanding of the prescribing dynamics of these lenses.

What Makes More Sense

Those of us who prescribe medically necessary contact lenses understand that the arcane and confusing current system is not well fitted to how a patient and a prescriber go through the process of prescribing a new lens or lenses to manage the patient’s changing condition.

Billing for the prescribing visit, then billing for the dispensing visit, and then billing for the subsequent visits separately is easy to understand and execute. Finally, basing the service code on the condition easily establishes medical necessity. 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.