I deal with the same issues over and over when talking to my colleagues. One of the biggest areas of confusion in coding and billing of medically necessary contact lenses continues to be the collision of CPT principles and the way that vision care plans use, or misuse, the CPT codes.
Let’s begin at the beginning, though. The basics of CPT principles start with medical necessity. CPT codes are only to be used when billing for a service, test, procedure, or durable medical equipment (DME) that is medically necessary. The establishment of medical necessity is the foundation of medical coding and billing. Therefore, the use of CPT codes when billing for medically necessary contact lenses is correct. I agree that the vision care plans (VCPs) should be using CPT codes.
The second principle is that to the extent that the plain language of a particular CPT code text is not ambiguous, the code text governs unless modified by a pre-text preamble and/or post-text instructions.
For example, the 9231x codes have a significant pre-text preamble that modifies all 9231x codes. The 92071 and 92072 codes each have post-text instructions that modify them, respectively. With this reality in mind, there are certain services required under each respective CPT code that is used for medically necessary contact lens prescribing that must be delivered and documented for the code to be billed, paid, and to survive audit.
The third principle is that any service, test, procedure, or DME that has its own CPT code should never be considered part of any other CPT code. Therefore, it should never be bundled with any other CPT code.
I have ranted about this issue before. For example, Blue Cross and Blue Shield (BCBS) decided that corneal topography is part of a comprehensive general ophthalmological service (92002/92012). Because corneal topography has its own code (92025), it is a violation of CPT guidelines to combine them, because that is code bundling. BCBS requires, by contract, that providers abide by CPT, and then it asks for something that contradicts that principle.
In another example, VSP requires the use of the CPT code 92310 for many different lens types, but the 92310 code is appropriate only for a “corneal lens.” The only corneal lenses on the market are GP corneal lenses. So, the only correct use of the 92310 is when prescribing a corneal GP lens for a diagnosis other than aphakia or keratoconus.
Further, the VCPs require the bundling of services into the 92310 or the 92072 rubric in a manner that greatly inflates the fee for this service. The bundling of services for the VCPs, while using them correctly for the other payors, causes a great deal of confusion that leads to bad coding mistakes. For example, EyeMed uses the 92310 CPT code with its own modifiers to describe a variety of diagnoses for which practitioners might use any manner of different lenses. Other VCPs, while not using modifiers, do use the infamous 92310 code for almost all medically necessary prescribing.
So, what am I saying here? I think that it is important for all prescribers of medically necessary contact lenses to understand very clearly that they basically need two “operating systems” in their heads—the correct way for coding and billing CPT codes to the private and public medical plans and another system that the VCPs require because of their incorrect use of CPT. Each VCP is different, so read their policies carefully, and follow their rules exactly. CLS