A couple of years ago, I wrote two articles in which I advocated redoing the schema for the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) Codes for medically necessary contact lens prescribing. I want to revisit this idea.

I am supposed to be some kind of expert in coding and billing for medically necessary contact lenses, and while I brag about the home runs in payment that we get from some of the carriers and vision care plans, I have to admit that I am taking a few hits these days in reimbursement; I’m beginning to feel the same way I did when I was forced to bone up on coding and billing in the first place.

So, what is happening? First, the need for medically necessary prescribing was greater than the payers thought it was. The payers thought that they could offer a high-perceived-value benefit that really wouldn’t cost that much and would truly make life quite a bit better for a few of their prescribers. However, the number of people for whom a contact lens used as an optical prosthetic is the difference between working and starving was higher than they thought—it was higher than we thought.

Second, through design and fabrication innovation, these lenses became easier to prescribe. And, as more prescribers jumped into the game to address the unmet need and the untapped opportunity, more claims started flowing through the system. This new reality affected the carriers from a payout and administrative standpoint.

The payers then answered this increase in utilization with new rules and stricter audits. After straightening these things out as best we could, we are starting to see prior-authorizations and denials with these lenses, not to mention approved reimbursements that frequently don’t cover the invoice costs of these lenses. Combined with carrier write-off adjustments and no room for balance billing, prescribers are left with not only no profit, but with the prospect of a successfully filed claim resulting in a monetary loss. This situation is untenable.

Let’s Try This Again

What I proposed two years ago was a Delphi group that would identify the conditions for which contact lens prescribing would be considered medically necessary rather than cosmetic and that the CPT 92310 through 92319 would be re-designated—American Medical Association (AMA), is that possible? Or, we use the codes 92073 through 92080 with new relative value units (RVUs). They would be unilateral codes with the bilateral exemption. We would specifically designate all services defined within the codes and define specifically what the terms mean in a preamble that would apply to all codes. We would do the same thing with the HCPCS V25xx codes so that they accurately describe the available lens categories. We have a lot of open codes between V2531 and V2599. We could easily expand this list.

Once we did all of the leg work, we would go to the AMA Editorial Panel to finalize these codes. Once that process was completed, we would work together to create policies that make sense (e.g., realistic reimbursements for materials that reflect the realities of the invoice costs and proportional balance billing to patients for the overages).

Yes, the cost of redoing these codes would be a lot for the AMA, the U.S. Department of Health and Human Services, and the payers, but let’s get it done. Anyone with me this time? CLS