Article Date: 2/1/2007

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Insurance Coding for Keratoconus Lens Fitting

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