Not Getting Paid for Contact Prescriptions? You Will After You Read This

92310 won't cut it - but this strategy for keratoconus and aphakia patients will
You know you can't bill Medicare for regular refractive contact lenses, but you can expect reimbursement for contact lenses for patients presenting with keratoconus and aphakia -- if you know these expert rules of the road.
Prove Medical Necessity for Keratoconus Patients
Situation: A 16-year-old patient presents with distorted and blurred vision along with glare and light sensitivity. The optometrist diagnoses keratoconus (371.60-371.62) and fits special contact lenses to correct the problem. You know that 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) isn't right, since the patient's carrier considers it to be a refractive error correction. Is there a more specific code you can use to describe the procedure?

Solution: To avoid denials when prescribing a contact lens to treat keratoconus, use 92070 (Fitting of contact lens for treatment of disease, including supply of lens), says Brenda Arendt, CMC, of the Center for Total Eye Care in Westminster, Md. Keratoconus is "a non-inflammatory, self-limiting ectasia of the axial portion of the cornea ... characterized by progressive thinning and steepening of the central cornea," according to the Center for Keratoconus at www.kcenter.org. For mild cases of keratoconus, glasses may adequately correct the patient's vision. More severe cases of keratoconus may require hard or gas-permeable contact lenses.

Supplies: The kind of contact lens used to treat keratoconus is a "bandage contact lens" (BCL). Using 92070 in a patient with keratoconus shows that the lens is for treatment of a medical condition, not a refractive condition. And since the code specifies that it includes the supply of the lens, your regular Medicare carrier will reimburse you for the supply of the lens as part of the procedure fee -- so you shouldn't separately report the lens to a durable medicare equipment regional carrier (DMERC), Arendt says.

Documentation: Years ago you could bill both the service and the lens to Medicare, but this changed after Medicare conferred with a consultant who stated that the majority of the time an inexpensive, soft contact lens was used with the service. If your doctor was unsuccessful using a soft lens to treat a disease and must use the more expensive hard or gas-permeable lens, you can attempt to bill your carrier for the expense. To receive payment, you will need to send a brief explanation detailing why the doctor used the hard lens, along with chart documentation of the failed attempts at using a soft contact lens. You will also need to [...]