Article

THE BUSINESS OF CONTACT LENSES

THE FAQS THAT JUST WON’T GO AWAY

After 10 years and a lot of articles, when I sit down to write, I go through my old articles to make sure that I’m not writing the same article twice. That being said, I get the same questions at lectures and by email over and over. Some frequently asked questions (FAQs) just never die, and they go into my “zombie” pile. No matter how many times I answer the same questions, I keep getting asked the same questions.

It is also understandable that great confusion reigns when the 9231x codes have one set of rules and the 9207x codes have a different set of rules. Some of these questions reflect complicated differences between the way that Current Procedural Terminology (CPT) treats the prescribing codes versus the way that the vision care plans treat them. Layer these two realities on top of each other, and confusion is baked in.

Some of these questions, however, reflect a singular lack of understanding about the rules of CPT in the first place. Some questions are plagued by both sets of circumstances.

How to Use 92072

Take the CPT code 92072, for example. I wrote an entire article about this code and the 92071 code back in April 2014. It’s been five years since then, and there has been some change in the guidance. So, I think that I should go over them again.

First, they were prosecuted at the same time seven years ago. They follow a similar format with short text and multiple sub-text instructions. People confuse them because they were promulgated at the same time, and they follow similar language that is different from the other prescribing codes.

Let’s focus on the 92072 code in this column. The 92071 code is also a zombie FAQ code that I’ll talk about in my next column. The basic principle of CPT is that if a particular service, such as prescribing for keratoconus, has its own unique code, then it is never part of any other code, and it is always wrong to bill a different CPT code when prescribing for keratoconus. The 9231x codes are lens specific, whereas the 92072 code is condition specific.

The second rule of CPT is that, to the extent that the plain language is not ambiguous and is not amended by either pre-text or sub-text instructions, the code text rules. In the 92072 code, there is an ambiguous term—initial fitting. CPT Assistant has offered clarity on this term by stating, “If the lens needs to be changed because it no longer fits the patient’s needs, the fitting of a new lens is considered an initial fitting…” There was a time when “initial fitting” was being defined as “once-per-lifetime.” That interpretation was wrong.

The 92072 code is amended by three sub-text instructions. The first states to never bill a 92072 code and a 92071 code at the same time. The second sub-text instruction states that subsequent fittings should be billed as evaluation/management (E/M) or as general ophthalmological visits. These are both clear enough. The third instructs prescribers to report the supply of lens separately using either the 99070 code or the appropriate supply code (Healthcare Common Procedure Coding System [HCPCS] Level II) separately.

This instruction is a trap. The 99070 code is (almost) always a non-covered service. A basic principle of CPT and the contracts that we sign to be providers states that it is always wrong to code a service covered when billed in such a way that it becomes non-covered. The correct path here is to always use the correct HCPCS code for the lenses selected. Doing so will keep you out of trouble. CLS