The Business of Contact Lenses
The Answers to Your Most Frequently Asked Questions
BY CLARKE D. NEWMAN, OD, FAAO
I get asked a lot of questions about coding and billing. Some of them come straight from colleagues who know me. Some come from lecture attendees. Some come in through the GP Lens Institute website or from webinar attendees. I get lots of the same questions over and over again. So this month, I will address some of the most common.
The Questions Most Asked
Here are your top five most frequently asked questions.
1. Can I bill patients for the difference between what I charge and what the insurance company or vision care plan pays? The answer is: “It depends on the contract you signed to be a provider for that payor.” If the contract says that you can balance bill the patient, then you can bill the difference between your usual and customary charges and the scheduled reimbursement.
If the contract does not say you can do that, then you cannot do that; and, if the reimbursement amount for that service or material is not enough to cover costs and provide a decent profit, then you should not have signed the contract in the first place.
2. Can I charge different amounts for the same CPT code? You should really always charge the same fee for the same service code. You sign contracts not to charge one payor more for the same service than you charge other payors. Most of the time, this question arises because a practitioner wants to use the 92310 code for prescribing all of the various cosmetic lenses.
I advocate against using the CPT codes for services that are not medically necessary. I suggest that you use your own codes for these non-covered services. This suggestion can be a problem when it comes to the vision care plans (VCPs) because they do the same thing with these CPT codes, and it is not appropriate.
3. Is 92072 to be billed only once per lifetime because it says “initial fitting”? The answer is, “No.” The initial fitting is rationally meant to be the first fitting of each discrete fitting interval. This is the only rational interpretation of the plain language that maps onto the reality of medically necessary prescribing.
4. How do I get the maximum from VSP and EyeMed in prescribing for keratoconus? There is no “strategy” for maximizing the billing for keratoconus patients under the VCPs’ necessary contact lens policies. You should do what is in the best interest of the patient according to the standard of care. Deliver the correct services and materials to affect the proper physiological alignment of the lens(es) with the proper optics and medical supervision necessary to provide consistent vision correction for your ectatic patients.
Bill fully and correctly for these services and materials, and the fee will be what it will be. Sometimes it reaches the allowable amounts, and sometimes it is much less. Remember, it is not what you get paid, it is what you get to keep at audit.
5. What HCPCS code should I use for hybrid and silicone elastomer lenses? In my opinion, the answer for both is V2599. The “Contact lens, other type” code is the correct code because CPT requires providers to use the code that most closely matches the plain language of the code. There is no V25xx code that matches a lens that is partly a GP and partly a hydrogel lens. So, use V2599. The VCPs require you to use the V2599 for hybrids. Silicone elastomer lenses are not hydrophilic, so they go in the same category. Remember, you need letters of medical necessity with the V2599 code. CLS
Dr. Newman has been in private practice in Dallas 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 or advisor to Alcon, Allergan, AMO, B+L, EyePrintPro, GPLI, Johnson & Johnson Vision Care, SynergEyes, TruForm Optics, and Zeiss Optics. Contact him at firstname.lastname@example.org.