I serve on the Gas Permeable Lens Institute (GPLI) Board, where my board responsibilities include creating and curating the billing and coding section on the GPLI website. Each year, usually in August or September, I do a webinar on coding and billing for medically necessary or specialty contact lenses. This year was no different.
Either I am very good at this lecturing stuff and I stimulate many thought-provoking questions, or I am really terrible at it and, by confusing everyone, I stimulate many thought-provoking questions. Either way, there were more than 100 thought-provoking questions asked this year. And, because, it has been a while since I have addressed these questions in my column, I thought we would cover a couple of them this month.
Reimbursement for Keratoconus
One question stumped me, so I thought that I would lead off with it. The question concerned the two levels of reimbursement for keratoconus through the EyeMed benefit. EyeMed has two different levels of reimbursement for keratoconus based on certain severity metrics of the condition, which you can find in its policies. First is the “Emerging/Mild” category, for which the maximum reimbursement is $1,200. Second is the “Moderate/Severe” category, for which the maximum reimbursement is $2,500.
This difference is not small, and the question was what and how do practitioners bill when one eye is Emerging/Mild and the other is Moderate/Severe? I didn’t know the answer. And, as far as I can tell, EyeMed didn’t really know either. However, after discussing this policy concern with the right EyeMed personnel while I was at Vision Expo West, we now have clarity. EyeMed believes it should be billed at the higher level; when one of the two eyes is the more severe, practitioners should bill the Moderate/Severe category for both eyes. This new policy is consistent with CPT Guidance.
92072 Versus 9231x
The greatest number of questions ask for clarification on the difference between the 92072 prescribing code for keratoconus and the 9231x prescribing codes for all other medically necessary lenses. First, regardless of the type of lens, the 92072 code is always correct for any of the ICD-10-CM H18.6x codes. Second, the 92072 code covers only the prescribing or the “fitting” of the lens. All follow-up services, including the dispensing of the lenses, are billed separately. Subsequent “fittings” are billed as either evaluation and management (E/M) or as general ophthalmological visits. The “initial visit,” according to CPT Assistant, is for the visit during which the practitioner takes all of the measurements after the lens is deemed to “no longer meet the patient’s needs.” That does not mean once per lifetime as some have claimed.
The 9231x codes include many services—the prescribing and dispensing of the lenses, the patient instruction for lens wear and care, and follow-up visits through “adaptation.” This term is best understood as when the patient reaches the prescribed wearing time. Subsequent visits, including changes to the lenses that are not “incidental,” are billed as general ophthalmological codes per the pre-text preamble to the 9231x code section. These codes are used for any medically necessary prescribing that is not for a diagnosis of keratoconus.
When to Use 92071
The second most popular question concerns the prescribing for dry eye. Unless there is an ocular surface injury that a bandage contact lens will fix, the 92071—Bandage Lens Code is not correct. Most of the time, it is best to use the 9231x codes. The V2627—Scleral Cover Shell has some requirements that make it hard to use for dry eye for most patients. CLS