Article Date: 10/1/2013

The Business of Contact Lenses
The Business of Contact Lenses

More on Benefits for Visually Necessary Contact Lenses

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BY CLARKE D. NEWMAN, OD, FAAO

Picking up where we left off in the August issue, let!’s examine Vision Service Plan’s (VSP’s) Visually Necessary Contact Lenses benefit, and the other major Vision Care Plan benefit, EyeMed. There are two fee schedules under the VSP Visually Necessary Contact Lenses benefit: the “Covered and Base Visually Necessary Contact Lens Maximums,” and the “Visually Necessary Contact Lens Specialty Maximums.”

These schedules are diagnosisand service fee-driven. The harder-to-prescribe, costlier lenses go down the Specialty Maximum path, and others (for example, monthly replacement silicone hydrogel lenses for high ametropia) would go down the other.

VSP Specialty Maximum Codes

For the Specialty Maximum lens benefits, practitioners must use one of the following service codes and matching diagnosis codes: 92072 and Keratoconus, or the 92311, 92312, or 92313 and one of the diagnosis codes from the list provided in the VSP Online Manual table below. Clearly, there are several diagnosis codes that, when used with the four approved CPT codes, produce the Specialty Maximum fee schedule.

TABLE 1
VSP Visually Necessary Contact Lens Specialty Maximums
If billing with CPT code 92072, 92311 or 92312, 92313 or one of these diagnosis codes
264.6 370.63 371.16 371.46 371.58 743.42
279.50 370.8 371.20 371.48 371.60 871.0
370.00 371.00 371.23 371.49 371.61 871.1
370.01 371.01 371.30 371.50 371.62 871.5
370.2 371.02 371.31 371.51 371.70 871.6
370.03 371.03 371.40 371.52 371.71 871.9
370.04 371.04 371.41 371.53 371.73 940.2
370.05 371.05 371.42 371.54 371.82 996.51
370.06 371.11 371.43 371.55 379.31 V42.5
370.07 371.12 371.44 371.56 743.35 V43.1
370.61 371.13 371.45 371.57 743.41  

The number of units is important. “Annual Replacement” is one to two units, “Planned Replacement” is three to 360 units, “Daily Replacement” is 361+ units.

Using EyeMed

EyeMed’s benefit is found at portal.eyemedvisioncare.com. Go to “Providers,” then login, then go to “Manuals,” then go to “Section 9.” EyeMed’s four approved diagnoses are: Keratoconus, Anisometropia of ≥3.00D, a high Ametropia ≥±10.00D, and any case in which a contact lens can improve the acuity two or more lines compared to spectacles.

Call for authorization, then fax the Health Care Financing Administration 1500 forms to EyeMed. The diagnosis must be in box 19, and “Medically Necessary Contact Lenses” must be written across the top of the form.

For Anisometropia and high Ametropia, EyeMed will pay 95 percent of the usual and customary (U&C) charges up to $700 per calendar year. For Keratoconus, they pay 95 percent of the U&C charges up to $1,200 per year, and for Visual Improvement, they pay 95 percent of the U&C charges up to $2,300.

Practitioners must use their plan-specific modifiers after the prescribing code. For Anisometropia, use the –AN modifier after the CPT code. For high Ametropia, the modifier is –HA. For Visual Improvement, the modifier is –VI. Keratoconus has its own code, so there is no modifier. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a Diplomate in the AAO and a consultant to B+L and AMO. Contact him at cdnewman@earthlink.net.



Contact Lens Spectrum, Volume: 28 , Issue: October 2013, page(s): 48