Lens Coding: A Guide for Proper Reimbursement
CHARLES B. BROWNLOW, OD
Soft contact lenses have gone beyond their common
use as corrective lenses for refractive errors and have become a frequently used
option in managing some eye problems. Medicare and
major medical insurers often won't cover the fitting or supplying of contact lenses
for refractive correction, while most will cover contact lenses used for a valid
medical reason. Medicare has long covered the prescribing and supply of lenses for
the correction of aphakia, as well as lenses used to manage eye disease or as bandage
As is often the case, a practitioner develops expertise in
applying a regimen of care well before he establishes a logical value for the care
and expertise in reporting the care to the payer(s). In most healthcare offices,
the skill sets among doctors and staff for providing the services is very high.
On the other hand, providers in all specialties struggle with understanding and
applying the coding guidelines associated with Current Procedural Terminology (CPT)
and International Classification of Diseases (ICD), especially when expanding into
relatively new areas of care.
Proper Use of Code 92070
One CPT code that has fostered widespread confusion among doctors
and payers and has resulted in frequent payer rejections is 92070, "Fitting of contact
lens for treatment of disease, including supply of lens." Following are keys to
using it appropriately.
You can use the code only if the lens prescribed is
a lens that has FDA approval for use as a therapeutic contact lens, such as CIBA
Vision's Night and Day lens and B&L's PureVision lens. Medicare never reimburses
for the use of lenses that aren't FDA approved as therapeutic lenses for this
purpose. Other payers may.
92070 is unilateral, referring to the service of fitting
and the provision of a single therapeutic lens. If prescribing lenses for both eyes,
use the modifiers RT and LT for each eye (reporting on separate lines) or the modifier
–50 (reporting on a single line).
The code is a "special ophthalmological service" and thus
CPT considers it a separate service. That means you report it separately only if
it's applied uniquely and not as part of another service. It also means that it's
never reported alone. If and when 92070 is the correct code to report the service
you've provided, report it in addition to an office visit. Note:
Be aware that not all payers understand the rules, which means that some payers,
including some Medicare carriers, will disallow either the 92070 or the office visit
if you bill them together.
Base your choice of correct office visit code to combine with
the 92070 completely on the content of the patient encounter and thus upon the content
of the medical record. As with every choice of office visit code, consider the case
history, examination and medical decision-making or initiation of diagnostic and
It's conceivable to use 92070 with any of the 10 992XX series
evaluation and management codes or with any of the four 920XX series general ophthalmological
If you use other lenses (those FDA-approved for other purposes
but not as bandage lenses) to treat and manage eye disease, then bill the office
visit code and other appropriate procedures only, along with the supply of lenses.
Don't use 92070 to report the fitting and supply of the lens.
In some cases, it may be appropriate to report the
fitting and supply of contact lens(es) using the standard CPT code for the fitting
of contact lenses, 92310, in addition to the office visit code. This code may be
used to report the services related to the fitting and the supply of lens(es) or
it may be used to report the fitting and related services only, with the lens(es)
reported separately using the appropriate HCPCS code. For example, "92310 and V2520
contact lens, hydrophilic, spherical, per lens."
In these cases, bill for the replacement lenses as necessary,
using the CPT code designed for the purpose, 92326, "Replacement of contact lens."
Again, the code is designed to include the professional services related to replacement
(ordering, mailing, verification, etc.), so if you desire to report the cost of
the lens(es) separately, you would report the service with the –52 modifier
(reduced service), in addition to the HCPCS code appropriate to the lens(es) ordered.
Keep in mind that prescribing and fitting contact lenses
to manage eye disease will probably have a higher relative value than the same service
done purely to correct refractive error. You can clarify this by adjusting the fee
for 92310 as you deem appropriate and then using CPT convention, applying the –22
modifier (unusual procedural service).
For example, if you prescribe and fit contact lenses as an aid
in the management of a chronic corneal condition, you might report the service using
an office visit combined with 92310-22, including the value of the lenses in the
total fee and making the fee higher than the fee for lenses fit to correct refractive
As reference, national fee survey data for 92310 (standard,
non-therapeutic lens fitting, including the lenses) shows values of $115, $165 and
$210 for the 50th, 75th and 90th percentile, respectively.
As with 92310, when you use 92070 to report the fitting
of an FDA-approved lens for the management of eye disease, don't report the value
of the lens separately. Be sure that your fee for the service is adequate to cover
the professional service of fitting, with all of the appurtenant responsibility,
as well as the procurement value of the lens.
The 2005 Medicare relative value (RVU) for 92070 is 1.79, which
results in a national average Medicare reimbursement of $67.84 (arrived at by multiplying
the Medicare RVU by the national average Medicare conversion factor of $37.90, where
Fee = RVU x CF).
National fee survey data suggest about $133 as the 50th percentile
fee for 92070 ($170 for the 75th percentile and $200 for 90th percentile)
You and your patient will agree that the frequency of bandage
lens replacement is dictated by need, not by policy. We know that these lenses are
frequently displaced and lost and/or must be replaced due to damage or clouding.
With your help, patients will understand the value of the lenses and will also understand
the limitations of any insurance plan. Individual payers, including some Medicare
carriers, may have their own rules relative to the frequency of replacement. When
ordering replacement lenses for Medicare patients, be sure to have them sign an
Advance Beneficiary Notice (ABN), which assures that patients will pay you for the
service and for the lenses if Medicare denies the claim. Filling out the form is
also important in that it reminds patients of their primary responsibility for payment
if and when the payer deems that the care or materials are "not reasonable and necessary."
Any discussion relative to coding and reporting your services
to payers must include the reminder that there is no uniform policy for payment
of this service among payers. It's important for you to know the national standard
policy for each code you use. It's also important that you understand when each
payer abides by the rules and when they do not.
Frequent reference to provider handbooks, payers' web sites and
other reference materials is necessary to be sure that you and your staff are handling
these challenges as well as you can. Also, in knowing the rules better, it's often
possible to convince payers' representatives that your care should be covered and
your claims should be paid. It is worth the effort. CLS
Dr. Brownlow is the executive
vice president of the Wisconsin Optometric Association and is a consultant to Practice
Management Incorporated, a Wisconsin-based consulting firm specializing in the insurance
challenges faced by American doctors.
Contact Lens Spectrum, Issue: December 2005