Article

BILLING AND CODING FOR SPECIALTY CUSTOM CONTACT LENSES

Here’s how to ensure appropriate reimbursement for this professionally rewarding endeavor

Mastering the science and art of fitting specialty contact lenses requires constant attention to new research and emerging techniques and technology. For example, our rapidly evolving understanding of scleral shape, settling of vaulting lenses, oxygen transmission through a post-lens tear reservoir, and countless other details is contributing to our success with hybrid and scleral lenses. Maintaining our status as experts in this area requires constant review of the literature, demonstrated understanding of multiple lens modalities, and experience with complex ocular conditions, as well as equipment and devices built specifically for managing patients with complex anterior segment needs.

Expertise in one more critical area is necessary for a successful specialty lens practice. You and your staff must understand how to bill and code properly for this specialized care ­— or risk a scenario similar to the following.

HAS THIS HAPPENED TO YOU?

After seeing his patient’s astigmatism progress over a few years and checking topography and pachymetry, Dr. Doogood diagnosed the daughter of a long-time patient with keratoconus. He felt confident that custom soft toric lenses that correct for high cylinder would be successful for the patient. Feeling sorry that he had to report this diagnosis to the patient’s parents, Dr. Doogood reduced his fees and billed Eyemed for a general examination and contact lens evaluation.

At the dispensing visit, the patient’s visual acuity with the custom soft toric lenses was 20/40 in each eye. Dr. Doogood knew he could achieve better vision with gas permeable (GP) lenses, but prescribing GP lenses placed him in a difficult position. The fees billed were not meant to cover multiple visits with trial lenses and troubleshooting. Being a great doctor, instead of telling the patient that this was the best vision she could achieve, Dr. Doogood took time from his busy clinic to fit her with corneal GPs.

At the next dispensing visit, the patient’s visual acuity was 20/20 with the GP lenses, but she reported they were uncomfortable. She decided to continue wearing the lenses, but within a few days, she called Dr. Doogood to report that she could not adapt to them. He brought her back for a trial of piggy-back lenses. Although the patient said the comfort was much better, she called the office a few days later to report that the lenses dislodged three times a day. Dr. Doogood knew he could solve this problem with a hybrid lens, so he scheduled a return visit … and so on.

If any of this story sounds familiar, please keep reading.

WHAT WENT WRONG

Multiple failures occurred on multiple levels. First, when a doctor does not bill and code appropriately for his or her services, both parties become upset. It is human nature. The growing divide between expectation and reality leads to unhappiness. The patient was not prepared for multiple visits, because up until now, the doctor always got her contact lenses “right” on the same day. The doctor now sees the patient as a problem at each subsequent unplanned visit, and tensions rise.

Next, by definition, a patient with keratoconus cannot be coded as a general patient, because the most accurate code that describes the service provided must be used. In this case, the contact lens evaluation must be coded as 92072 (fitting of contact lens for management of keratoconus, initial fitting) and not 92310 (prescription of optical and physical characteristics of and fitting of contact lenses). Therefore, Dr. Doogood violated his contract with Eyemed, which would likely be revealed in an audit.

Finally, reflecting on this negative experience, Dr. Doogood decides that treating patients with keratoconus is not worth the cost of angering other patients when the clinic is delayed and not worth the frustration he experienced in the previous situation. During each of those return visits, Dr. Doogood was unable to see a patient with uncomplicated needs, therefore losing revenue for his professional services and potentially losing sales from the purchase of eyeglasses and contact lenses in his optical department. As a result of this one experience, Dr. Doogood stops managing patients who have keratoconus. This is in no one’s best interest.

WHAT SHOULD HAVE HAPPENED

If Dr. Doogood had billed appropriately for his services and educated the patient about what to expect, everyone would have benefited. Dr. Doogood would have used Eyemed’s medically necessary benefit procedure and included the cost of return visits in his evaluation fee, thus avoiding mounting frustration with each additional visit. The patient would have been informed initially that advanced contact lenses often require multiple office visits. Dr. Doogood would have explained that there are many options in contact lenses for patients with keratoconus, and that he was going to start with the simplest lenses and progress to more complex lenses, if indicated. Dr. Doogood and the patient would have been on the same page and worked as partners through the process until they achieved an acceptable outcome.

There are multiple methods for billing and coding for specialty custom contact lenses. The rules differ based on whether you’re filing a claim with vision insurers or medical insurers. Errors may cause serious consequences, including audit failure, recovery of reimbursements, removal from panels, civil litigation, and in the case of government payers, criminal prosecution.

The information presented here is based on years of filing medical and vision benefit claims for medically necessary contact lenses, successful audits from multiple insurers, and working directly with medical directors or medical advisory board members within various insurers.

VISION INSURANCE

Most vision insurance or vision care plans have a provision for medically necessary contact lenses (MNCLs) and should be considered primary when the patient has vision and medical benefits and the doctor is on both panels. Vision insurers share one common feature for medically necessary benefits: bundling. Vision plans pay the provider for the procedure codes used regardless of the number of visits required to complete the process.

The top two plans by numbers of subscribers are Eyemed and VSP, and they will be discussed individually later. In both plans, 90 days of services, including visits, testing, and lenses, are included in the MNCL benefits. Any medical problem that develops within this period, but outside the contact lens process (e.g., corneal abrasion, subconjunctival hemorrhage, corneal ulcer, etc.), is billed to medical insurance. Likewise, any care provided outside of the 90-day window but associated with the MNCLs should be billed to medical insurers.

For many practitioners, this process is new. The vision-defined section of the Affordable Care Act adopted this bundling model, in part, because of negotiations with the American Optometric Association (AOA). Previously, the rules for MNCLs were not clearly defined by the vision insurers. Practitioners ended up interpreting the rules themselves and often failed audits as a consequence. High utilizers of medically necessary benefits were confronted with recovery audits to find errors in interpreting the rules from the perspective of the payers. They had extrapolated penalties assessed (sometimes six figures) that in some cases were practice killers. Two of the chief negotiators from the AOA, Clarke D. Newman, OD, Dallas, and Stephen M. Montaquila, Warwick, R.I., went to the bargaining table with one of the vision insurers and helped create a system that was fair to all parties. The other major vision insurer recently followed suit and instituted a 90-day global period.

The concept of 90 days of covered services has an important consequence for your practice. To continue providing the service while remaining profitable, practitioners must achieve the maximum success in a reasonable number of office visits. If a patient’s stage of disease calls for simpler lenses, such as a custom soft toric or a vaulting hybrid that can be fit in fewer visits than a scleral lens, those options should not be overlooked.

Office visits must be managed properly to avoid disrupting other aspects of the practice. Patients who need MNCLs require substantially more chair time than patients who need general or medical care, and scheduling must account for these differences. Determining how to manage visits depends on the number of MNCL patients the doctor sees. In our practice, most patients require MNCLs, so we book on the half hour with high technician coverage. If your practice has a more varied patient population, you may want to book extra time and designate extra technician time for MNCL visits.

Vision insurers require practitioners to bundle all services for MNCLs into a few codes. This differs substantially from CPT rules and medical insurance guidelines. Therefore, when determining your fees for either 92072 (contact lens fitting for keratoconus) or 92313 (scleral contact lens fitting, used for diagnoses other than keratoconus, such as post-refractive surgery or dry eyes), you must build in the cost of each visit and each test you will be performing. Remember, you signed government and private contracts agreeing not to charge one payer less than another.

EYEMED

Diagnoses that support filing a claim for MNCLs include: aphakia, high ametropia, anisometropia, keratoconus, and vision that can be corrected two lines better with contact lenses than with eyeglasses. (In California, there are a few more provisions.) The plan maximums are listed under each category as follows:

    Aphakia: $700

    High ametropia: $700

    Anisometropia: $700

    Keratoconus mild/moderate: $1,200

    Keratoconus severe: $2,500

    Two lines improvement: $2,500

These fees include visits, testing, and lenses. Therefore, it is in the patient’s best interest (and mandated by your contract with Eyemed) that if he or she falls within one of those categories, you file the claim as MNCL.

High ametropia is defined as refractive error ±10.00D in one meridian at the spectacle plane. Anisometropia is defined as any meridian that differs by more than 3.00D. This is a departure from medical insurers, which do not consider high ametropia or anisometropia to be diagnoses that support medical necessity.

There is a provision for mild/moderate keratoconus and a separate one for severe keratoconus. For “emerging/mild” reimbursement, the patient should not have corneal scarring, but should have unstable topography, photophobia, corneal signs such as striae, a steepest corneal meridian of less than 53.00D, and corneal thickness greater than 475 microns. For the “moderate/severe” category, topography must be steeper than 53.00D, and minimum corneal thickness must be less than 475 microns. Of note, Eyemed’s maximum reimbursable amount is the same for vaulting hybrid lenses and scleral lenses for severe keratoconus.

VSP

For VSP, you must file an electronic claim through Eyefinity. After inputting the authorization number, you will see a series of drop-down boxes, one of which will ask for the type of lenses prescribed, which may include:

  • V2510 for corneal GP
  • V2521 for toric soft lenses (off the shelf or custom)
  • V2531 for scleral
  • V2599 for hybrid

You can find a full list of diagnoses that are reimbursed by VSP’s MNCL benefit in your provider manual.

Absent from the above list is V2627 for scleral shell, the typical code used to designate lenses for patients with severe dry eye when billing medical insurers.

The next drop-down box is key for MNCLs. You can select either “Elective Contact Lenses” or “Necessary Contact Lenses.” After filling in the rest of the requested information, VSP checks to see if you have satisfied the criteria for MNCLs. If so, the claim is processed electronically.

Maximum reimbursement for scleral lenses for 92072 and 92313 with VSP is $2,500. However, in your contract with VSP, you agree to give a 10% discount to VSP members, so your maximum reimbursement is actually $2,250. Maximum reimbursement for hybrids with VSP is $1,200.

MEDICAL INSURANCE

Medical insurers do not bundle fees. All claims follow CPT guidelines. In other words, you code separately for any procedure or test you perform.

Common procedure codes used for coding MNCLs for medical insurers include:

99214 — Return comprehensive examination

92072 — Fitting of contact lens for management of keratoconus, initial fitting

92313 — Prescription of optical and physical characteristics of and fitting of contact lens; corneoscleral lens

92025 — Corneal topography

92132 — Anterior segment OCT

76514 — Pachymetry

92015 — Refraction

V2599 RT, LT — Contact lens, miscellaneous

V2627 RT, LT — Scleral cover shell

V2531 RT, LT — Contact lens, GP, scleral

Coverage of procedures related to MNCLs varies widely among medical insurers. I recommend having patients sign an advance beneficiary notification every year when you are managing their MNCLs. Patients insured by Medicare are required to sign this form. This document explains that the patient is financially responsible for any procedure determined by their insurance to be a noncovered service. From experience, I can tell you that it is well worth a conversation with the patient about this document prior to initiating services. For example, some carriers (including Medicare) reimburse for 92132, anterior segment OCT, for evaluating the cornea in the presence of a contact lens; however, some insurers summarily exclude this test as “experimental,” and the patient is financially responsible for it. If you know a patient’s insurance excludes this test, it is best to find out ahead of time whether or not the patient wants the test performed.

Maximum reimbursement for office visits, testing, and lenses also varies widely among carriers. It is best to evaluate each insurer’s contract and fee schedule prior to signing your annual contract. Some insurers’ fee schedules for MNCLs are not acceptable to our practice, therefore, we choose not to be included in those panels. With a carefully crafted letter and a receipt for services from your practice, those patients whose insurance we do not accept but who elect to proceed with MNCLs are often successful at recovering out-of-network benefits from their carriers.

SUMMARY

Prescribing MNCLs is intellectually and financially rewarding to the practitioners who are able to do so efficiently, ethically, and skillfully. Their patients enjoy the best vision possible, comfort, and wearability, and they become patients for life. No business disruptor will be able to take that away. Making a living at prescribing MNCLs takes just as much study as the science of prescribing, because as I tell my staff, “In today’s world of managed care, it’s not what you bill and code. It’s what you can keep after an audit that matters.” CLS