Ophthalmology and Optometry Coding Alert

Get your deserved reimbursement for medically necessary lenses.

Seasoned ophthalmology coders know there’s a world of difference between contact lenses to correct refractive error and lenses that are necessary for a medical reason. Knowing the difference – and which CPT^® and HCPCS codes to report – can mean the difference between a successful claim and a denied claim.

Read on for our expert answers to frequently asked questions about contact lens coding.

Question: Is coding for medically necessary contact lenses different than coding for elective contacts?

Answer: Yes. Many carriers, including Medicare, will not cover correcting of refractive error, including with contact lens prescriptions. That service – described by CPT^® code 92310 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia) – is “non-covered by statute,” according to Medicare’s Billing and Coding Guidelines for Optometrist Services.

“Beneficiaries may be billed for these services,” say the guidelines. “The beneficiary should be notified these services are non-covered and informed of the cost the physician will charge for the service.”

You do not need to bill 92310 to Medicare, unless the patient requests that you do so in order to get a denial that he can then use to get payment from another payer. In these cases, report 92310 with modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) appended.

Medically necessary lenses: If the ophthalmologist is prescribing contact lenses to treat a condition other than refractive error, there are more appropriate CPT^® codes to choose from, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. For aphakia (absence of the natural lens), you would report one of the following:

• 92311 – Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia,  1 eye

• 92312 – corneal lens for aphakia, both eyes

• 92313 – corneoscleral lens.

For therapeutic contact lenses, report one of these:

• 92071 – Fitting of contact lens for treatment of ocular surface disease

• 92072 – Fitting of contact lens for management of keratoconus, initial fitting.

History: These two services used to be covered under one CPT^® code, 92070 (Fitting of contact lens for treatment of disease, including supply of lens), but CPT^® deleted that code in 2012 and added 92071 and 92072. Ophthalmologists were using 92070 to report two very different kinds of services with “substantially different levels of work,” noted Medicare at the time.

Contact lens management for keratoconus (a condition in which the cornea is unable to hold a round shape) is more labor-intensive than management of ocular surface disease – reflected in the fact that Medicare reimburses on average $38.45 for 92071, compared to $136.19 for 92072.

Note: For subsequent fittings for keratoconus lenses, CPT^® directs you to report either an E/M (9921X) or ophthalmological management (9201X) code.

Question: How should I code for the supply of the lens?

Answer: CPT^® instructs you to report the supply of the lens separately with either 99070 (Supplies and materials [except spectacles], provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) or the appropriate HCPCS supply code:

PMMA (polymethylmethacrylate) lenses:

• V2500 – Contact lens, PMMA, spherical, per lens

• V2501 – … PMMA, toric or prism ballast, per lens

• V2502 – … PMMA, bifocal, per lens

• V2503 – … PMMA, color vision deficiency, per lens

Gas permeable lenses:

• V2510 – Contact lens, gas permeable, spherical, per lens

• V2511 – … gas permeable, toric, prism ballast, per lens

• V2512 – … gas permeable, bifocal, per lens

• V2513 – … gas permeable, extended wear, per lens

Hydrophilic (soft) lenses:

• V2520 – Contact lens, hydrophilic, spherical, per lens

• V2521 – … hydrophilic, toric, or prism ballast, per lens

• V2522 – … hydrophilic, bifocal, per lens

• V2523 – … hydrophilic, extended wear, per lens

Scleral lenses:

• V2530 – Contact lens, scleral, gas impermeable, per lens

• V2531 … scleral, gas permeable, per lens

Don’t miss: For contact lens modification for these lenses, CPT^® directs you to code 92325 (Modification of contact lens [separate procedure], with medical supervision of adaptation).

Other type:

• V2599 – Contact lens, other type

Know payer preference: Some payers will want supplies reported with V codes, while others want to see CPT^® code 99070 with an invoice attached, Mac warns. “Reporting the V codes alone without an invoice of materials and supplies provided may automatically deny in the claims adjudication process,” she says. “It will be necessary to determine how payers want these supplies reported. Further, some payers require electronic submission of these claims and will only allow you to appeal them after the initial denial with proof of cost (invoice), or require other additional information such as the progress note to justify medical necessity.”

All of these V codes are monocular (per lens), so if you treat both eyes, you should report two units of the applicable V code. You may also append modifiers RT (Right side) and LT (Left side), depending on the payer’s preference.

Question: How should I code if a technician – not an ophthalmologist – provides the contact lens services?

Answer: Look to these CPT^® codes:

• 92314 – Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes except for aphakia (for prescription and fitting of one eye, add modifier 52)

• 92315 – ... corneal lens for aphakia, one eye

• 92316 – ... corneal lens for aphakia, both eyes

• 92317 –  ... corneoscleral lens.

“These are the special codes for techs doing the work,” explains Mac. “Techs are employed by the physician and work under their direct supervision, so it should still be billed out by the physician providing the supervisor for the tech’s work.”