FOR YEARS, I have maintained the Coding and Billing module of the GP Lens Institute (GPLI) website. One of my duties is to do a yearly webinar to update prescribers and billers on coding and billing.

However, I recently had to do an update after a webinar because there were enough changes in vision care plans’ (VCPs’) visually necessary contact lens benefits that we had to talk about those changes.

First, over the past few years there has been significant consolidation of the VCP market. This consolidation is part and parcel of the continuing vertical integration of the vision care markets. For several years, EyeMed and Aetna Vision have been associated as independent contractors. UnitedHealthcare purchased Spectera Vision in 2001. More recently, Versant Health acquired the Superior Vison and Davis Vision plans.

For many years, Vision Service Plans (VSP) and EyeMed had significantly higher reimbursements for necessary contact lenses, but that has changed recently. Beginning in January 2023, Spectera Vision and Superior Vision totally revamped their visually necessary lens policies and reimbursements.

Before I begin, I strongly advise each prescriber and biller to read the visually necessary contact lens policies of every carrier with which they contract. This read should take place annually.

My office annually copies the online policies of these VCPs into a PDF under the Fair Use Doctrine, and I place these documents on the desktops in the exam room and administrative area computers so that we can look up the polices quickly and authoritatively.

Each of the VCPs has a limited data set of qualified conditions that have per se coverage under their respective necessary policies. There is significant correlation between the VCPs, but there are differences of which eyecare providers must be aware.

First, VSP’s and EyeMed’s policies are roughly the same as they have been in previous years. For VSP, the biggest change is the addition of the following: “Corneal Refractive Therapy, Orthokeratology, and contact lenses for Myopia Management are not covered under necessary contacts, covered contact lenses or the VSP Elements Plan. Patients can use their elective contact lenses allowance towards the cost of Corneal Refractive Therapy, Orthokeratology, or Myopia Management contact lens materials only. The Contact Lens Fitting and Evaluation portion of the treatment is a private transaction between you and the patient.”

It is important to know that the VSP benefit only covers services for the first 90 days of care. “Any fitting fees incurred after the initial 90-day period are considered a private matter between you and the patient.”

EyeMed prescribers and billers are advised to read up on the delineation between mild/emerging and moderate/severe keratoconus. Further, read up on the various carrier-specific EyeMed code modifiers. EyeMed has seven code modifiers for all of the qualifying criteria except keratoconus, which has its own Current Procedural Terminology (CPT) code.

Make sure that for the mild/emerging keratoconus patient to use the H18.61x “Stable” codes, and for the moderate/severe keratoconus patient use the H18.62x “Unstable” codes.

Spectera, too, has a limited data set of covered conditions, but they only have a single code modifier, -XC, for all necessary prescribing. Make sure to append your prescribing codes accordingly.

Superior Vision, like Spectera, has a single modifier, -KX, to delineate necessary prescribing. Also, Superior lists myopia management as a covered service and Superior now has an online portal for submitting claims.

Do your homework regarding these changes and follow the rules! CLS