Fitting specialty contact lenses isn’t always as straightforward as fitting conventional contact lenses, but broadening your skill set can open up a wider, more diverse patient base. As the health care system evolves, more eye care practitioners are moving toward the medical model of optometry, and one of the fastest growing areas in the profession is medically necessary contact lenses. Billing and coding for this service with different insurance providers are constantly changing, which can be confusing. In this article, I provide some guidance on what constitutes medical necessity, common codes, and things to keep in mind when dealing with vision insurance.
THE BASICS
Following are Current Procedural Terminology (CPT) codes from the American Medical Association that describe the fit if performed by a physician or technician for medically necessary contact lenses.1
The prescription of contact lenses includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, oxygen permeability). It is not a part of the general ophthalmological services.
The fitting of a contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period.
Follow-up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service. (92012 et seq) The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code.
The supply of contact lenses may be reported as part of the fitting. It may also be reported separately by using the appropriate supply code.
92310 (92314*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens, Both Eyes, Except for Aphakia
92311 (92315*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens for Aphakia, One Eye
92312 (92316*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneal Lens for Aphakia, Both Eyes
92313 (92317*) – Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, With Medical Supervision of Adaptation; Corneoscleral Lens
(*) Denotes codes for same service when provided by a technician.
92071 – Fitting of Contact Lens for Treatment of Ocular Surface Disease. This usually refers to bandage contact lenses used to manage recurrent erosions and corneal abrasions.
92072 – Fitting of Contact Lens for the Management of Keratoconus. Verify with the insurance company what criteria are required for the diagnosis of keratoconus and grading of its severity. Also, determine if the insurance provider prefers that lenses be billed for separately or as a bundle.
9921X or 92012 – For Subsequent Fittings Report Using Evaluation and Management Services or General Ophthalmological Services
After the fees, timeline, and expectations of the contact lens evaluation process have been discussed, it is important to have patients sign a written contract that includes an advance beneficiary notice (ABN). ABNs require patients to make an informed decision on whether they or their insurance company will pay for the services and goods provided. If the claim is denied, patients are aware that they are financially responsible. The written contract discusses all the charges involved in the treatment plan (eg, office visits, warranties, lens upgrades, supplies needed, timeframe of the treatment plan).
An ABN offers the following three options2:
Option No. 1
I want the ______ listed above. You may ask to be paid now, but I also want _____ billed for an official decision on payment, which is sent to me on a summary notice. I understand that, if _______ doesn’t pay, I am responsible for payment, but I can appeal to ______ by following the directions on the Medicare summary notice. If _______ does pay, you will refund any payments I made to you, less copays or deductibles.
Option No. 2
I want the ______ listed above, but do not bill ______. You may ask to be paid now because I am responsible for payment. I cannot appeal if _____is not billed.
Option No. 3
I don’t want the ______ listed above. I understand that, with this choice, I am not responsible for payment, and I cannot appeal to see if _____would pay.
V Codes
These codes (Table 1) are used to bill for the materials (ie, contact lenses) and may have a modifier for the right or left eye. These codes are used on insurance forms and are universal. You may also have to indicate the quantity of lenses.
INSURANCES
Every vision insurance provider has its own expectations. Following are some key points to keep in mind when fitting medically necessary contact lenses for patients with EyeMed Vision Care, VSP, and Spectera, which are the three insurance providers my practice deals with most often.
EyeMed Vision Care
EyeMed considers contact lenses medically necessary if a patient is diagnosed with anisometropia, high ametropia, mild or advanced keratoconus, or vision improvement (Table 2).4 The provider will then submit clinical documentation, corneal topographies (for patients with irregular corneas), and Health Care Financing Administration form to the patient’s insurance, which will usually approve or deny the claim within 1 to 2 weeks.
VSP
In order to verify what VSP considers medically necessary, log in and scroll down to visually necessary contact lenses (NCLs) under “plans and coverage” in the “manuals” section.5 Specific eye conditions can be corrected only with contact lenses. These include:
- Nystagmus;
- Anisometropia in which the difference based on the spectacle prescription is 3.00 D or more;
- High ametropia (≥ ±10.00 D) in either eye based on the spectacle prescription;
- Achromatopsia, polycoria, congenital anisocoria, and certain pupillary abnormalities;
- Keratoconus;
- Aniridia;
- Corneal transplant;
- Hereditary corneal dystrophies;
- Albinism.
This claim can be filed electronically on e-Claim. No prior authorization is required.
For patients with high ametropia or anisometropia, it is important to enter the spectacle prescription into the lab order so the insurance provider can verify that the condition meets medically necessary requirements.
When billing for scleral and hybrid contact lenses, use HCPCS V2530 or V2531. Not indicating the type of lens (scleral or hybrid), the manufacturer, and the brand of the lens in box 19 will lead to lower reimbursement—V2510 rate. The number of units or lenses will also be needed for the claim.
Irregular astigmatism is not covered.
Note: Visually necessary contact lenses aren’t typically covered for patients who have received elective cosmetic eye surgery (eg, LASIK, PRK, radial keratotomy). Postoperative concerns, however, such as ectasia, scarring, and corneal irregularity that cause vision problems that require correction with contact lenses to provide functional vision are covered under the NCL benefit, so long as patients meet the NCL criteria.
Bills for medically necessary contact lenses are submitted via Eyefinity, and payment can be expected in about 2 weeks.
Spectera
United Healthcare owns and operates the Spectera Eyecare Network, which bills exams and materials together and has probably the quickest and easiest form to fill out because only the usual and customary fee are on the form that is faxed to the insurance. It is important to bill with the XC modifier. The provider simply submits the exam results, corneal topographies (for irregular corneas), the Health Care Financing Administration form, and sometimes a letter that supports the documentation provided. It usually takes about 2 to 4 weeks for approval and payment.
Below is a list of the conditions that Spectera approves for the use of medically NCLs:
- Keratoconus;
- Aphakia;
- Irregular corneal astigmatism;
- Anisometropia;
- > 3.50 D acuity <20/70 with glasses and > 20/70 with contact lenses;
- Corneal deformity;
- Corneal opacity;
- Corneal degeneration;
- Corneal ectasia;
- Corneal transplant;
- Facial deformity.
A WORTHWHILE INVESTMENT OF TIME AND EFFORT
Medical billing and coding can be tricky because the system is never static. At my office, we wait for full payment from the patient or for the contracted reimbursement from his or her insurance company before dispensing lenses. The more accurate the billing and coding, the sooner the payment can be deposited, allowing lenses to be dispensed in a timely manner.
It is therefore important to understand what each specific insurance carrier defines as medically necessary and what criteria are required to meet medical necessity. You should be able to find this information in a provider manual or by contacting the insurance company to verify that you will be paid for your materials and services. Listening to webinars, attending lectures, and reading relevant journals are some ways to keep up with billing and coding changes that occur over time. Once you start learning about billing and coding it becomes easier, and fitting medically necessary contact lenses can lead to a fulfilling career that is also financially rewarding.
- 1. American Medical Association. CPT 2021 Professional Edition. Salt Lake City, UT: American Medical Association; 2020.
- 2. Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566. Centers for Medicare & Medicaid Services. Accessed May 3, 2021. www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-Instructions.pdf
- 3. Assorted contact lenses HCPCS code range V2500-V2599. Codify by AAPC. Accessed May 3, 2021. www.aapc.com/codes/hcpcs-codes-range/442.
- 4. Welcome to the online claims processing system. EyeMed Vision Care. https://claims.eyemedvisioncare.com/claims/loginForm.emvc. Accessed May 10, 2021.
- 5. Harmon H, Caswell J. Vision insurance FAQ: frame, lens & contact lens benefits. VSP Individual Vision Plans. January 17, 2020. Accessed May 3, 2021.
- www.vspdirect.com/vision-hub/vision-insurance-frame-lens-contact-benefits
