The Business of Contact Lenses
VSP’s Visually Necessary Contact Lenses Benefit
BY CLARKE D. NEWMAN, OD, FAAO
When we discuss coding and billing for medically necessary contact lenses, we are almost always referring to the process for qualified health plans, such as indemnity payors. The vision care plans (VCPs) are different animals altogether. This month we will look at Vision Service Plan’s (VSP’s) “Visually Necessary Contact Lenses” benefit.
Remember that it doesn’t matter what I say; it only matters what the written policy says. So we must first turn to the VSP Manual for 2013. Once you log in at www.eyefinity.com, click on “VSPOnline” down the right-hand side. Next click on “Manuals,” then “VSP,” then under “Plans and Coverage,” click “Visually Necessary Contact Lenses.”
What the Benefit Covers
First, for patients who have VSP and might need medically necessary contact lenses, your staff needs to determine whether their particular plans have the “Necessary Contact Lenses” benefit or whether it is excluded. If they do have this benefit, your staff has to make sure that they have not used it during the qualification period. They get only one bite at the apple during the benefit period.
The chief complaint, the history of present illness, and the medical record must support one of the following approved diagnosis codes: Aphakia, Nystagmus, Keratoconus, Corneal Transplant, Corneal Dystrophies, Anisometropia of ≥3.00D in any meridian, Ammetropia ≥10.00D, and Irregular Astigmatism. Notice that corneal disfigurement is not on this list. You cannot bill VSP for cosmetic prosthetic lenses.
You file your VSP claims in eClaim. For the anisometropia and high ammetropia diagnoses, you need to provide the spectacle prescription. When you prescribe a scleral lens or a hybrid lens, put the lens brand in box 19.
When it comes to the lenses, bill the correct Healthcare Common Procedure Coding System “V” Code. VSP requires that you use the V2599 code for hybrid lenses. There are two scleral lens codes, V2530 and V2531. I use the V2530 code for corneoscleral lenses of 16.00mm or less and V2531 for the bigger, more expensive lenses. I follow the same procedure for VCPs and indemnity carriers to ensure a consistent rationale for the use and the fees for those lenses.
The piggyback benefit is available to qualified recipients who are intolerant to GP lenses. Again, the piggyback lens information goes in box 19. There is a benefit for spectacle lenses over the contact lenses when patients are aphakic, presbyopic, have high ammetropia, or have an accommodative disorder, binocular disorder, or require different amounts of prism at distance and near. You have 30 days to file for the spectacle lenses, for which you must call VSP for a claim number and provide the prescription for the lenses. Patients must pay for or provide the frame.
For everything but keratoconus, bill the appropriate 9231x code and bundle the prescribing and follow-up visits. You need to estimate the number of visits. Do the same for keratoconus, but use the 92072 code. This code is for the prescribing of the lens only, so you have to fudge a bit. Much as I hate to say that, the VSP system does not exactly comport with CPT. You will receive 85 percent of your usual and customary fees. There are two fee schedules—“CL Maximums” and “CL Specialty Maximums,” depending on the lenses.
My next column will finish up VSP and address EyeMed. 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 firstname.lastname@example.org.