In my lectures on coding and billing for medically necessary contact lenses, I have the same slide in the presentation twice because it is very important. It simply states, “What I say doesn’t matter…sort of.”

The average prescriber attends lectures, watches webinars, and reads articles written by the so-called “experts.” It is primarily for one to stay abreast. However, there is just one catch—the “experts” are either right or wrong about what they tell you. The good news is that they are overwhelmingly right. Yet, when they are wrong, they wreak havoc.

When it comes to coding and billing for the services and materials we provide, the good news is that the overwhelming majority of what we need to know is written in guidance by payors. The bad news is that it changes frequently, without any substantive notice.

It Depends.

Here is another problem: What is said in a lecture may or may not apply directly because of the plans that practitioners contract with or the administrative entities that control those contracts. There are 12 Medicare Administrative Contractors (MACs) that have jurisdiction over Medicare Parts A and B (Centers for Medicare & Medicaid Services [CMS], 2022). A MAC’s Local Coverage Determination (LCD) indicates whether it will cover a particular service. Coverage criteria within each LCD include a list of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) codes that define which services are covered or considered necessary and reasonable.

Contractors often have different rules, as stated in their LCDs, that change the answers to some questions. It gets worse for other organizations that comprise dozens of independently operated entities in the U.S., Washington, D.C., and Puerto Rico. All of these differences cannot be accounted for in a one- or two-hour lecture or a 600-word article.

So, regardless of what is heard in a lecture, the practitioners have the sole responsibility for complying with the various contracts that they sign or complying with statutes and regulations. I still get questions about the CPT Code 92070 (aka the bandage contact lens code). There is just one problem: that code was retired in favor the new code, 92071—in 2012!

Unraveling and Deciphering the Guidance

Here is an example of the experts leading you astray by misconstruing the real guidance. When billing for the new test for keratoconus, the 2012 guidance on this issue states that Medicare and, therefore, most payors, do not cover this test as a screening test. One of the prominent code heads left it at that. However, the next sentence states that a family history plus a sign or symptom, such as decreased acuity, for example, does justify payment.

These nuances are sometimes missed by even the best code heads. So, when billing for this test, make sure to document in the history that there is a sign or symptom that is rational to keratoconus. Further, document that sign or symptom by appropriate testing.

Another nuance that is often missed when blindly following code heads’ advice is that payor policies cannot dictate what tests the practitioners conduct. Practitioners are bound to the standard of care. Yet, they can do a test like this for a parent’s peace of mind when a child is at genetic risk; however, the parent must pay out of pocket for the test. CLS

REFERENCES:

1. CMS. What’s a MAC. 2022 Jan. 12. Available at cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC . Accessed Oct. 19, 2022.
2. Department of Health and Human Services. Memorandum Report: Coverage and Payment for Genetic Laboratory Tests, OE1-07-11-0011. 2012 Jun 12. Available at oig.hhs.gov/oei/reports/oei-07-11-00011.pdf . Accessed Oct. 19, 2022.