I recently gave my annual webinar on coding and billing for medically necessary contact lens (MNCL) prescribing for the GP Lens Institute (GPLI). There were many questions regarding how to code and bill for these lenses.

So, let’s circle back to some basic concepts that should prove helpful in billing correctly, getting paid maximally, and, most important, getting to keep the reimbursement at audit. I always say that it is not what you get paid that counts, but what you get to keep at audit.

Keeping Reimbursements

If you’ve prescribed in the medically necessary space for some time, you will come to realize that contracted payers surveil the contracted providers for errors, fraud, and overbilling. They maximize their resources by going after the outliers. In this case, the payers use what is called utilization review.

If the average contracted prescriber in a geographic area prescribes for two MNCL patients per month and you are prescribing for 10 MNCL patients per month, then your utilization is significantly higher than the average. This means your head is sticking up out of the gopher hole, and the payers just love to lop it off.

Unfortunately, high utilization is also the mark of an expert in this area, yet you will most likely get audited frequently. So far in 2022, I have been audited twice—once by a medical carrier and once by a vision care plan (VCP). Following the procedures set forth in the respective provider manuals, which must be checked annually to make sure to account for changes in policies, and solid documentation make these audits relatively stress free.

However, if practitioners fail to play the game properly, they will pay recoupments based on extrapolations of their demonstrated failure rates, which are often bill-backs for up to five years, with interest and penalties. So, play by the rules, keep documentation, and take no flak from the auditors.

Scleral Add-On

The next issue that came up in the recent webinar was the concept of billing for scleral lens add-ons. In today’s scleral lens market, we have microvaults and notches, toric haptics and optics, multifocals, and coatings. During the webinar, one attendee questioned whether there was a method for charging for these lens add-ons. The short answer is “no.”

The longer answer is that the Common Procedural Terminology (CPT) Level II codes, or Healthcare Common Procedure Coding System (HCPCS), are mostly material codes that are considered categorical and not material specific.

For example, the HCPCS code for a scleral lens is “V2531.” The plain language text for this code is “contact lens, scleral, gas permeable, per lens.”

One can see from this description that the plain text descriptor is describing a “type” of lens, or a category, and not a specific proprietary lens design. As such, it is contemplated under the Level II regime for different fees to be charged for different proprietary products that are rational under this specific code. So, when there are add-ons and warranty costs, it is correct to add those additional costs to the fee charged for the lens.

These codes are different from Level I codes that function under the relative value units (RVUs) regime. The fee only varies based on two factors—the provider level (physician or allied health) and the geographic practice cost index (GPCI).

When we bill a Level I code like a 92002, for example, we are contracted with all payers not to charge more to one carrier for the same service. So, charge the same for Level I codes and vary the costs of Level II codes based on your costs. CLS