PROPERLY CODE FOR YOUR SERVICES

THE ACCELERATED resurgence of scleral lenses has taken place within the last five to seven years as broader, widespread adoption has taken hold. As scleral lenses become a mainstay of clinical practice, it is important to understand how to create your medical record, code and bill for a scleral lens fit.

CODE FOR THE APPROPRIATE LENS

Let’s start with the lenses themselves. It is important — in any contact lens fit — to properly code for the materials you are using.

Below are the two Healthcare Common Procedure Coding System (HCPCS) Level II codes specifically describe a scleral lens, followed by the 2017 CMS National Average reimbursement amount:

• V2530 — Contact Lens, Scleral, Gas Impermeable, Per Lens ($230.52)
• V2531 — Contact Lens, Scleral, Gas Permeable, Per Lens ($521.22)

Other material codes that may be applicable depending on the technology you are using would be — again followed by the 2017 CMS National Average reimbursement amount (where available):

• V2599 — Contact Lens, Other Type (N/A)
• V2627 — Scleral Cover Shell ($1,590.08)

The above codes are all a per lens reimbursement amount. This is important in developing your business case and your patient communication.

Please keep in mind: It is very important the lens type provided to the patient and the V codes used match up. Many carriers now request invoices, in addition to standard documents, as they adjudicate their coverage policies.

One more thing before we leave the topic of lenses: Don’t confuse coverage with reimbursement or your fees. You should be setting your fees based on a consistent methodology across the patient spectrum without bias or discrimination. What the patients’ third party benefits for materials are and what your fees are should be considered two separate and distinct issues.

MATCH UP THE CORRECT FIT WITH ITS CPT CODE

When fitting a scleral lens, use the proper subset of contact lens fitting codes provided by the CPT.

In the CPT, the section begins with the following language that applies to all contact lens fits: “The fitting of contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.”

The codes below describe the fit when performed by the physician, according to the CPT.

• 92310 — “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.”
• 92311 — “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye.”
• 92312 — “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes.”
• 92313 — “Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens.”

Note: While the CPT description of the 92313 code does not specify unilateral or bilateral, further research shows that it should be considered a unilateral fit.

In many situations, “incidental revision of the lens during the training period” and “with medical supervision of adaptation” are accomplished at the first post-contact lens dispensing visit.

Once the proper vision and comfort criteria are met, and you are either at the point where you have ordered the final lenses or have provided the patient with his or her contact lens prescription, the patient can now be considered fit for the contact lenses and the service period for that particular code is over.

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. This is because you are then managing an ocular condition or complication, not “following the contact lens.”

INCORPORATE SCLERAL LENSES

Incorporating scleral contact lens fitting into your practice, broadens the scope of services that you can offer to your patient community and benefits your practice. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com.