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THE BUSINESS OF CONTACT LENSES

MORE FAQs THAT JUST WON’T GO AWAY

In my June column, I wrote about a few zombie FAQs that simply won’t go away. And because I have only so many words in this column, here are some more questions about Current Procedural Terminology (CPT) Code 92071, the bandage lens code. The questions that I get about CPT Code 92071 are three-fold.

1) What Lens?

First, does the contact lens have to be a U.S. Food & Drug Administration (FDA)-cleared lens with an indication for therapeutic use? The answer lies in the Centers for Medicare & Medicaid Services (CMS) National Carrier Determination (NCD) 80.1. The contact lens does have to be cleared by the FDA to meet medical necessary. However, a requirement for a therapeutic indication is not addressed.

2) What Conditions?

Second, does the code cover conditions such as keratoconus? Well, the short answer is “No.” The Principles of CPT demand two things. To start, if a service or procedure has a unique CPT code, then that service or procedure is not part of any other service or procedure—regardless of what any insurance company says about topography being a part of a comprehensive ophthalmological examination. Therefore, using the 92071 code for prescribing a contact lens for keratoconus is always incorrect. However, if an eyecare practitioner is treating an ocular surface condition in a patient who happens to have keratoconus, then he or she may use the 92071 code for that purpose only.

The other important CPT Principle in this situation is that to the extent that the plain language of the code text is unambiguous, unless it is modified by sub-text instructions, a pre-text preamble, or a carrier determination, it is followed.

Let’s look at the plain text of the 92071 code: “Fitting of Contact Lens for Treatment of Ocular Surface Disease.” By definition, keratoconus is not an “ocular surface disease.”

In addition, as mentioned earlier, the 92071 code is controlled by NCD 80.1, which lists a variety of conditions that qualify for the use of a lens as a bandage. This list does include corneal ectasis, but because keratoconus has its own prescribing code, it does not fall under this rubric.

3) Billing

Third, I get questions on billing for the lenses. The 92071 code, like the 92072 code, has sub-text instructions about how to bill for the lens and a prohibition against using 92072 and 92071 at the same time. Respectively, they read: “Do not Report 92071 in Conjunction With 92072” and “Report Supply of Lens Separately With 99070 or Appropriate Supply Code.”

A quick aside, never use 99070 to report the contact lens supply. It is always a non-covered code. The contracts that practitioners sign with the various payors state that it is a violation of our contracts to bill for a service, procedure, or material in a manner that would render said service, procedure, or material non-covered when, if billed correctly, it would be otherwise covered. In other words, practitioners cannot game the system to charge a patient their usual and customary fee when it would be otherwise covered when properly coded. Use the appropriate Healthcare Common Procedure Coding System (HCPCS) Level II code, or “V” code, for the materials.

The sub-text instruction about billing for contact lenses aside, NCD 80.1 supersedes this instruction when it says, “Payment for the lens is included in the payment for the physician’s service to which the lens is incident.” So, do not submit payment requests for lenses dispensed to Medicare recipients.

While the NCDs are only applicable to CMS patients, most private payors follow these codes as well. Eyecare practitioners need to find out whether a payor will pay for the lens separately.

One More

Last, but not least, the mother of all zombie codes is the old bandage contact lens code, 92070. I still get emails about how to bill the 92070 code. For the record, the 92070 code was discontinued in January 2012 when the 92071 code was promulgated. Stop using 92070!!! CLS