BUSINESS

  coding strategy

CPT CL Codes

Reimbursement tips for contact lenses in your medically oriented practice

JOHN RUMPAKIS, O.D., M.B.A.

Contact lenses are a hotbed of frustration for many on the medical coding and reimbursement side of things. Coding the proper type of contact lens fit is critical to your reimbursement success.

In order to properly document your medical record and use the proper Current Procedural Terminology (CPT) code to describe the appropriate services provided, you must understand and keep up with the current definitions of the contact lens fitting codes as described in the CPT.

Though this is not a complete list, here are the most frequent codes you will use, as defined by the Current Procedural Terminology 2015 – American Medical Association.

Traditional CL fitting codes

• 92310 Contact Lens fitting: Prescription of optical and physical characteristics of and fitting of a contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia. A 92310 should be charged for the fitting of contact lenses and encompasses services up to the point at which you would issue a contact lens prescription.

This code does not include contact lens follow-up care after the lenses have been dispensed. This code is charged every visit a new lens is placed on a patient’s eye or the fit is altered. Incidental revisions, such as power changes, without altering the fit are not billed as a new fitting.

Keep in mind that the modifier –52 should be used if fitting only one eye. Note: This is a change that was implemented in 2011, as opposed to the –RT or –LT modifier that was used prior to that date.

• 92313: Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens.

Therapeutic uses of CL codes

• 92071: Fitting of a contact lens for treatment of ocular surface disease. Report materials in addition to this code using either 99070 or the appropriate Healthcare Common Procedure Coding System (HCPCS) Level II material code. This is a UNILATERAL code.

• 92072: Fitting of a contact lens for management of keratoconus, initial fitting. Please report materials in addition to this code using either 99070 or the appropriate HCPCS Level II material code. This is a BILATERAL code.

Keep this specific quotation of the CPT in mind: “For subsequent fittings please use either the 9921X or 9201X codes.”

Remember that you are not following the contact lens, you are following the keratoconic cornea, and the contact lens is a treatment paradigm.

Refining and/or modifying your fit

In most cases, “incidental revision of the lens during the training period” and “with medical supervision of adaptation” are accomplished at the first visit following contact lens dispensing.

Once the proper vision and comfort criteria are met, and you have either ordered the final lenses or provided the patient with his contact lens prescription, the patient can now be considered fit for the contact lenses.

Again, should complications arise, the most appropriate way to bill for office visits is using the established patient ophthalmologic (9201X) or evaluation and management (9921X) codes. Keep mind that with many, if not most, specialty contact lens fits, you are following a corneal or OSD disease state and not the contact lens.

Many O.D.s are giving away thousands of dollars per year by including this “free care.” Never consider a fitting fee to be a global, yearlong obligation to provide unlimited service at no charge.

If you refit a patient, and it is not just an “incidental revision of the contact lens,” then another fee for 92310, 92311, 92312 or 92313 would be an appropriate code to bill along with the appropriate materials V-code or HCPCS code for lens supply.

Insurance benefits for specialty contact lenses vary greatly, so know your policies and how to use an Advanced Beneficiary Notice (ABN) properly. Use the appropriate modifier –GA, –GX, –GY, or –GZ appended to the CPT or HCPCS code to indicate to the carrier that the patient has received appropriate disclosure of personal financial responsibility and has attested to that with their signature on the ABN form.

Rewarding results

Building a specialty contact lens practice can be a very rewarding endeavor in the broad spectrum that is now optometry. Employing cutting-edge technology and our expertise of both optics and the ocular surface, optometry can serve our patients very well by providing the best patient outcomes while keeping our practices safe and profitable. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.