On average, I get about two questions a day regarding coding and billing for medically necessary lenses. In the past, I have printed the answers to questions that I get frequently on both the GP Lens Institute’s website and in this column. I think it is time to do this again.
Coding for Scleral Lenses
The first question I get over and over is the use of the CPT Healthcare Common Procedure Coding System (HCPCS) Level II code V2627. The plain text of the code is, “Scleral cover shell.” Many practitioners are drawn to this code because of the high reimbursement. However, it is almost never the appropriate code.
The V2627 code is subject to the Centers for Medicare and Medicaid Services’ National Carrier Determination (NCD) 80.5. This longstanding policy has two parts. The first describes a lens designed to cover a “... sightless and shrunken ...” eye to “... obviate the need for surgical enucleation and prosthetic implantation.” Unless you are an oculist, you won’t be making these kinds of prosthetic cover shells.
The second paragraph of the NCD 80.5 is applicable: “Scleral shells are occasionally used in combination with artificial tears in the treatment of ‘dry eye’ of diverse etiology ... When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by the use of the scleral contact lens as a protective barrier against the drying action of the atmosphere ... The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal gland and would be covered as a prosthetic device in the rare case when it is used in the treatment of ‘dry eye.’”
Implied in this paragraph is that the eye may be sighted, because it does not describe a sightless eye as in the first paragraph. Some guidance incorporates the first paragraph into the second, thus implying that the lens does not qualify under this determination if it is used to correct vision, so you should check with the carrier.
The V2627 code, when you do use it, should be billed to the Durable Medical Equipment Center because it incorporates the cost of the scleral lens. For the most part, even when using the scleral lens for dry eye, the cost and process for prescribing such a lens does not differ from a scleral lens used to correct something other than dry eye. So, it is easier to get paid if you use the 92313 service code and the V2531 material code.
Hand-Painted Lens Coding
Another question I get often concerns billing for cosmetic hand-painted lenses. Cosmetic lenses are not always medically necessary; when they are not, you may bill for them as you wish. I never use CPT codes for non-covered services and materials. That way, I can charge what I want for such services, and these fees cannot be construed as charging two carriers different amounts for the same services.
These lenses are medically necessary when they act as some form of light occluder for photophobia. Vision care plans (VCPs), particularly VSP, have begun to recognize this and have added this reason to the list of approved necessary diagnoses.
When billing other than a VCP, use the unlisted service and material codes 92499 and V2599. Always submit a letter of medical necessity describing how the service and material are medically necessary. Make sure to submit the invoice cost for the lenses, as they are often more expensive than the allowable. CLS