In June, I tackled some of the most common questions I get about coding and billing for medically necessary contact lenses. This month, even though I have written about the following in 2014 and in 2019, I still get many questions about it, so here goes. First, how should we bill for dispensing visits and subsequent follow-up visits? The answer: it depends on the prescribing code used. If you use the Current Procedural Terminology (CPT) code 92072 for keratoconus, then that code covers only the prescribing of the lens. It does not cover the examination of the eye, nor does it cover the dispensing of the lenses, the patient instruction, or the necessary follow-up visits.

As I have said many times, the plain language of a CPT code text rules to the extent that it is not ambiguous. The plain text of the 92072 code is, “Fitting of lens for management of keratoconus, initial fitting.” However, the language here is ambiguous in two respects: what constitutes “fitting of lens,” and what is an “initial fitting”? So, a clarification was issued in CPT Assistant that states:

“The description of work for initial fittings includes the results of diagnostic test done prior to contact lens fitting to assess the corneal ectasia, which are used in concert with slit lamp examination to assess corneal shape and determine initial contact lens parameters (e.g., diameter, base curve and secondary curves). Lens designs can include corneal, scleral, hybrid, or piggyback systems. Keratometry, lid anatomy, tear film and refraction are also performed and/or rechecked. If the lens needs to be changed because it no longer fits the patient’s needs, the fitting of a new lens is considered an initial fitting and should include all of the services above,” (American Medical Association, 2017).

“Fitting” Defined

The term “initial fitting” applies only to the first visit of each discreet fitting interval. After that, the 97072 subtext instructions tell prescribers that “For subsequent fittings, report using the Evaluation and Management [E/M] Services or General Ophthalmological Services.”

You might also see that the professional component (Modifier –26) of the 92025 “Computerized corneal topography, unilateral or bilateral, with interpretation and report,” is implied to be included in the term “initial fitting.” For codes rational to the diagnosis of keratoconus that have technical components (Modifier –TC) and professional component, the correct billing is for the technical component, as the “description of work for initial fittings includes the results [emphasis added] of a diagnostic test done…” Currently, that would only be the 92025 code.

When using the 9231x prescribing (fitting) codes, the answer is different. All eight of the 9231x codes have the same plain language text up to the semi-colon: “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation;…”

Further, the pre-text preamble for the 9231x section of codes states that “The fitting of a contact lens includes the instruction and training of the wearer and incidental revision of the lens during the training period.” Taken together, these two instructions speak about adaptation and training period, both of which can rationally be defined to mean the time needed to reach the prescribed wearing time. And, yes, I do write that in the record. Incidental revision can be rationally defined as a change made to the current lens. A substantial change would require the making of a new lens.

After that period, the preamble instructs prescribers to use General Ophthalmological Service Codes. Subsequent guidance could be construed to mean that the E/M Codes can also be used. CLS

For references, please visit www.clspectrum.com/references and click on document #311.