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Insurance
Coding for Keratoconus Lens Fitting
BY
CARLA J. MACK, OD, FAAO
For those of you who fit keratoconus
patients in your practice, you're no stranger to the confusion surrounding the proper
use of the codes 92310 and 92070 to designate the fitting process for
this corneal disease. You've probably also faced the frustration when your reimbursement
for services (especially when choosing 92070) seemed inappropriately low and, in
some cases, didn't even cover the cost of the contact lenses you ordered to fit
the patient.
When to Use Which Code
At first glance (Table
1), there's apparent overlap between the codes because they both identify a contact
lens fitting procedure. However, 92310 also takes into account the determination
of the contact lens prescription, which includes lens power, base curve(s), diameter,
material and all other identifying optical and physical characteristics of the lens.
CPT 92070 doesn't require an additional
supply code (such as V2510, V2520, etc.) to designate the contact lens type provided
to the patient. When using 92310, you may report the patient supply as part of the
fitting or as an additional appropriate supply code.
The more appropriate procedure code
when treating a disease process is 92070. The primary purpose of the contact lens
in such a case is not for visual function. The primary purpose of the contact lens
is to promote healing, decrease pain, aid in therapeutic drug delivery and/or help
maintain ocular surface hydration. The contact lens is part of the rehabilitative
process or treatment plan.
Other indications include treatment
of corneal pain and corneal epithelial disruption in neurotrophic keratitis, filamentary
keratitis, Thygeson's superficial punctate keratopathy, bullous keratopathy and
corneal dystrophies.
The CPT code 92070 is a unilateral
code and requires the appropriate –RT or –LT modifier correlating to
the eye that has been fit. Personally, I have designated the use of this code almost
exclusively for therapeutic bandage lens situations as described above.
In the early stages of keratoconus
when the patient has minimal corneal signs and limited or no symptoms, spectacles
may provide adequate vision. Of course, spherical soft contact lenses or soft toric
contact lenses may also be options for satisfactory vision. In the case of soft
spherical or soft toric contact lens fitting, most of us agree that CPT 92310 describes
this fitting process well.
Defining "Medically Necessary"
When you fit a large- or
small-diameter GP contact lens or a specialty soft contact lens that is medically
necessary for adequate or good vision for your keratoconus patients, do you view
the fitting differently? Does medical necessity for adequate vision indicate that
you should code and bill CPT 92070?
Not exactly. The GP contact lens
isn't treating or rehabilitating the corneal ectasia. However, it is necessary for
providing good vision. And, as you probably know, it often takes considerable effort
over a number of visits to find the best optical prescription with the best fit
for the cornea. A great deal of time is spent on the lens-to-cornea fitting relationship
and on achieving the best visual correction as well as on maintaining good corneal
physiology with the contact lens.
For these reasons, it's my opinion
that CPT 92310 better represents the fitting process for keratoconus patients. The
supply of the contact lens is not incorporated into the fitting process and thus
requires an additional lens "V code" designation as well.
Reimbursement for 92310
Do medical insurance plans
view procedure code 92310 with an additional keratoconus diagnosis code (371.6X)
as a medically covered procedure? The answer is a definite maybe. Medicare does
not reimburse contact lens fitting for keratoconus. Requesting prior authorization
from the patient's medical insurance carrier with a letter stating the codes, costs
and reasons for medical necessity may assist with claim coverage.
Trying to determine an appropriate
fee for the fitting process that best represents your 92310 even with a medical
diagnosis such as keratoconus will leave you mystified. You can bill intermediate
comprehensive eye examination codes (920XX) and evaluation and management codes
(992XX) in addition to your 92310 fitting.
When using a piggyback contact lens
system such as a silicone hydrogel contact lens with a GP lens for your keratoconus
patients, bill the 92310 with an appropriate fee in addition to the appropriate
two or four material V codes (V2510 and V2520) depending on a unilateral or bilateral
fitting.
Dr. Mack is a
Diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry
and the director of clinics at The Ohio State University College of Optometry.
Contact Lens Spectrum, Issue: February 2007