Billing Medically Necessary Contact Lenses

8:40 PM

So in my first year of practicing, insurance billing has been the biggest learning curve I have faced.  They try to prepare you in school.  They try to prepare you at your externships.  But the problem is that billing and coding seem to be changing every couple months.  Here is a review of the latest coding conundrum I have faced:

Insurances for Medically Necessary Contact Lenses
First off, not all insurances are going to offer any coverage for contact lenses.  With time and experience, you will learn which insurances reimburse anything.  So far I have successfully filed to VSP, Eyemed, and Superior Vision for visual conditions that require contact lens correction.  Medical insurances like Blue Cross are not going to cover anything for vision correction.   Medicaid (at least in NC) will offer some base level of reimbursement if filed correctly.  On the contrary, if you have a corneal abrasion or another condition where a bandage contact lens is appropriate, medical insurances like Blue Cross WILL offer coverage and vision insurances will not.

Medically necessary contact lenses for post-RK

Not all vision insurances cover medical contact lenses for vision correction to the same amount of reimbursement. Some insurances will reimburse cost of lenses and evaluation fee.  Some will only give a certain amount of dollars to be applied toward eval or lenses.  Just remember, if you are going to try to bill for contact lenses, do NOT use the patient's insurance benefits towards glasses.  Once the insurance has been used, they won't provide for anything else.

What Conditions Typically are Covered
Again, different insurances have different guidelines, but here are the most commonly accepted reasons for medically necessary lenses:

  • Keratoconus, pellucid marginal degeneration, or a corneal degenerative condition where vision improves in contact lenses versus glasses
  • High anisometropia (usually there are guidelines about how much, typically between 3D and 5D minimum)
  • Condition where best corrected vision improves by at least 2 lines with use of contact lenses versus glasses (this includes high refractive error conditions)
  • Bandage contact lenses for treatment of ocular surface conditions (this is typically with a medical office visit code and is billable to medical insurances, unlike the previous items)
Synergeyes ClearKone lens is a great option for medically necessary keratoconus correction
For most insurances, you will need to submit paperwork detailing the condition which requires medically necessary contact lenses for treatment.  Sometimes they ask for your "usual and customary fees."  Some insurances don't care because they are only going to give you a blanket amount anyway.

What Codes to Use
Here's where things get tricky.  After you have done the paperwork and started your complicated contact lens fit process, nothing is worse than getting that rejection letter back due to a coding issue.  Yes, this just happened to me.  Why?  Because unbeknownst to myself, coding for medically necessary contact lenses changed on January 1st, 2012.  Some insurances are still accepting your contact lens fitting code (typically a 923xx code) linked to the appropriate medical condition (like keratoconus).  The new CPT method of doing this (this means the new RIGHT way of doing things) now includes specific medical contact lens codes.  Your codes are:
  • 92071  Fitting of contact lens for treatment of ocular surface disease (this is your bandage lens code)
  • 92072  Fitting of contact lens for management of keratoconus
  • 99070  Supply of materials (I have never tried billing this, but apparently you can bill this with a bandage lens code)
In the past if doctors were billing vision insurances, they never used these 9207X codes with their fit.  Typically this coding was reserved for bandage lenses.  But then I got a rejection the other day requesting the appropriate keratoconus fit code.  It's hard to remember adding yet another code to your examinations, but if it means the difference between the patient getting coverage and having to pay fully out of pocket, these codes mean a great deal!  Even if you get a rejection, you can always call the insurance company and investigate why your request has been denied.  Sometimes a simple coding fix is all it takes.

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1 comments

  1. VSP will cover lenses for glasses if needed over visually necessary contact lenses. For example, I wear Kerasoft IC for keratoconus and I also get glasses because of presbyopia. In my case it is a toss-up over just paying OOP for over the counter readers.

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