Medically Necessary Contact Fit and Materials

Lexington, KY
Best answers
Trying to figure out the best way to bill and receive reimbursement for scleral contact lenses. My doctor wants to use 92313 with H18.59 diagnosis, but Medicare allowable reimbursment is only $90.71. With contact lenses the total charge will be $2500.
If you Google "billing for medically necessary contact lenses" you should find a recent article by Dr. Rumpakis on this subject. It's pretty comprehensive and should give you a way to increase your reimbursement. Remember that some of the fitting codes, 92313, are unilateral codes, so you bill that for each eye.

Also, each of your follow up visits should be billed individually as 92012, versus trying to code and bill for all of your services up front.

Also remember to have the patient sign an ABN for Medicare patients or a modified ABN for patients covered by other carriers, so the patient knows they are responsible for paying any fees that the insurers deny. You are most likely not going to get your entire fee, as you would for a cash paying patient, but, if you do it correctly, you can still generate a reasonable income for these types of fits.

Be sure to document everything precisely as to visits and materials costs. Some of the vision plans, especially VSP are really cracking down on these types of fits and if your doctor does a lot of them, there will most likely ba an audit at some time.

Tom Cheezum, O.D., CPC, COPC