With keratoconus as an example, coding for the patient’s experience

Building an advanced contact lens clinic requires focus, investment in the proper equipment and an understanding of how to get reimbursed for your time. This article will focus on the latter.

FIRST VISIT

Make sure your staff understands the unique billing steps for custom contact lens fitting, so that everything can be documented and ordered to meet the coding requirements.

For example, a patient has an exam, is diagnosed with keratoconus and is fit with contact lenses. At the first visit, an exam is billed and coded with a 92xxx (eye exam codes) or 99xxx series code (E/M codes). Remember, the eye exam codes require the initiation of a diagnostic and treatment plan, while the E/M codes require documentation of history, exam and medical decision making.

FOLLOW-UP VISIT

Next, keratoconus diagnostic tests at that visit or at a follow-up visit are ordered. Coding for this would look as such:

1. 92072. This code is used for the fitting of a contact lens for the management of keratoconus.
2. 92025. Computerized corneal topography, unilateral or bilateral, with interpretation and report. Code 92025 is defined as “unilateral or bilateral,” so reimbursement is the same whether one or both eyes are tested.
3. 76514. Ophthalmic, ultra-sound, diagnostic; corneal pachy-metry, unilateral or bilateral, determination of corneal thickness.

Be sure to read what each code covers to make an appropriate decision. For example, code 92072 only includes the initial fitting.

ANNUAL SUPPLY

The supply of the lenses should be charged separately using the V code that best matches the lens design and material. For keratoconus, this may be:

- V2513 Gas permeable lens, extended wear, per lens

- V2530 Hybrid contact lens

- V2531 Gas permeable scleral lens, per lens

- V2599 Contact lens, other type, per lens

RE-FIT VISIT

As for re-fits, subsequent visits should be reported using either E/M codes or general ophthalmological codes, which most closely describe the encounter. The contact lens re-fit would be billed as well, using 92310 combined with either 99070 or the V code that most closely matches the type of lens used.

CPT 92310 can be used with different levels of contact lens fitting (standard, complex, advanced, etc.). Fees can be set that are higher than your standard 92310.

Additionally, for advanced fits (e.g. a toric GP), you can use the modifier 22 on the 92310 to indicate the higher level of service, complicated fit, etc. Modifier 22 comes into play when the work required to provide a service is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it (i.e. intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). This modifier should not be appended to an E/M code.

HAVE A CONVERSATION

While some optometrists have had success in getting reimbursed for medically necessary contact lens fittings and annual supplies, unfortunately, most insurers will not pay, even with a medical diagnosis. It is important to let your patient know he/she will likely be responsible for payment, such as: “I know your eyes have this unique condition, but most medical insurance plans do not cover the cost of your contact lenses very well. The staff can help assist you with your exact situation.” OM

DR. MILLER is a partner at Eyecare Professionals of Powell, Ohio. He is past president of the Ohio Optometric Association. Dr. Miller has received honoraria for consulting, lecturing, research or acting in an advisory capacity from: Alcon, Allergan, Bausch + Lomb, J&J Vision Care, Revolution EHR and Shire.