Fitting medically-necessary contact lenses (MNCL) can be extraordinarily satisfying and challenging. Unfortunately, one of the challenges may be getting paid for your services and materials.
The code for bandage lens fitting and supply (92070) is usually a poor choice for MNCL fits because the reimbursement—$60 to $85 for the fit and lenses, per eye—is a fraction of the proper amount for a complex case.
A better approach: Bill the appropriate code for the “prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation” using:
• 92310—Corneal lens, both eyes, except for aphakia.
• 92311—Corneal lens for aphakia, one eye.
• 92312—Corneal lens for aphakia, both eyes.
• 92313—Corneoscleral lens.
Append modifier -22 to the 9231x codes to alert the carrier to the greater amount of time and complexity for this procedure. Double the usual rate is not uncommon, and twice the normal fitting time is recommended before using this modifier. Expect to submit further documentation to the carrier to justify this higher fee. A letter of explanation, including full color topographic maps, often fulfills this requirement.
Remember to bill for the lenses separately using the appropriate V-codes (such as V2513 or V2531, as you’ll often use a gas permeable extended wear lens). Bill for both soft and GP lenses if performing a piggyback fit.
Refitting and Monitoring
CPT contact lens services states, “The fitting of contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.”
In most cases, “incidental revision of the lens during the training period” and “with medical supervision of adaptation” are accomplished at the first post contact lens dispensing visit. Once the proper vision and comfort criteria are met, the patient can now be considered fit for the contacts. Should complications arise, the most appropriate way to bill for office visits is using the established patient ophthalmologic (92000) or evaluation and management (99000) codes.
Never consider a fitting fee to be a global, year-long obligation to provide unlimited service to the patient at no charge. If you refit a patient, and it is not just an “incidental revision of the contact lens,” then another fee for 92310, 92311, 92312 or 92313 would be an appropriate code to bill along with the appropriate materials V-code or Healthcare Common Procedure Coding System (HCPCS) code for lens supply.
Some special codes are often necessary when fitting MNCL:
• Corneal topography (92025). This is probably the best way to monitor progression of keratoconus or other corneal disorders, especially using change analysis features of the instrument.
• Bandage contact lenses (92070). These can be used when epithelial defects arise.
• Anterior segment photography (92285). Use this to follow progression of endothelial folds, scarring, etc.
• Endothelial photography and cell count (92286). This is great for following degenerative changes to the endothelial cell layer resulting in therapeutic decisions.
• Pachymetry (76514). Use this to monitor progressive thinning of the corneal apex.
Remember to consult your local carrier’s medical policies for specifics on billing and coding rules. Many doctors, myself included, call the insurance carrier first to see if they will reimburse for medically-necessary contact lenses. If there is an exclusion for all contact lenses, then we tell the patient at the initial visit what the total charges will be and exactly what the fee does and does not cover, including lens exchanges and office visits. n
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