By Clarke Newman, OD, FAAO
I. The 92072 Code
Q: The 92072 code is listed as covering the “initial fit only.” Can I be reimbursed for this code if the patient has been previously fit by another provider?
A: There is a dispute about whether or not this “initial fitting” means once per lifetime or the first visit of each discrete prescribing episode. I believe it is the latter. Having worked on the 92072 Editorial Committee representing the AOA as a stakeholder, I am sure that we discussed this initial fitting to mean the same thing that we mean with the first fitting of a 9231x code.
Q: What’s the best way to handle ongoing contact lens evaluation charges, since the 92072 is covered only once? Do we just charge the patient out-of-pocket?
A: All follow-up visits are, essentially, evaluations of the underlying condition in the presence of the contact lens. As directed by the preamble to the 9231x codes and the sub-text of the 92072 code, these visits are billed as covered services to the patient’s insurance carrier using the CPT code and the appropriate ICD-9-DM code for the service provided. The one exception to this rule is the MNCL benefits under the vision care plans (VCPs). These plans require you to bundle the follow-up with the prescribing.
Q: Am I correct to assume that the 92072 code pertains not exclusively to soft lens fittings but also to other cases, as for example, a scleral lens design on a keratoconus patient?
A: I was the AOA stakeholder advisor to the CPT Editorial Committee that created the 92072, and nowhere was its limitation to soft lenses only ever discussed. The text and sub-text language for the 92072 code reads:
92072 — Fitting of Contact Lens for Management of Keratoconus, Initial Fitting
- For Subsequent Fittings, Report Using Evaluation and Management Services or General Ophthalmological Services
- Do not Report 92072 in Conjunction With 92071
- Report Supply of Lens Separately With 99070 or Appropriate Supply Code
The basic rule of CPT contracts with payors demand that we follow is that the plain language of the code text rules. However ambiguous the language or text instructions, there are either pre-text instructions in a preamble or an authoritative carrier determination policy that alters the meaning.
There is no pre-text instructive preamble to the 92072 code. There are three sub-text instructions, which as you can see above, do not specify a soft lens. The plain language of the 92072 text is clear and unambiguous. So, that leaves some authoritative carrier determination from CPT or CMS. I have seen no NCD from CPT through either CPT Change or guidance through CPT Assistant or anything from CMS.
I would challenge anyone to show me that interpretation in a CPT Change directive or a CMS Pub-100. To my knowledge, only one CMS directive has been issued on the 92072 code, and it is contained in MLN Matters 7745 from March of 2012, and it concerns the unilateral/bilateral change.
Now, some payor may require that, and that decision should be appealed immediately, but it does not apply to the industry as a whole and certainly should not be adopted as a policy by your billing department.
Q: If it is a bilateral or unilateral code, since it first was changed in January, 2012 there seemed to be some doubt or confusion with a clarification later, so some practitioners may still be unsure on this aspect.
A: Unilateral codes are disappearing — with intent on the part of HHS. The 92072 code was originally intended to be unilateral, but Medicare decided on its own in January of 2012 to make it bilateral, and the whole world followed suit.
II. 9231x Codes
Q: Is there any concern with the use of the 92313 code for vision plans that cover medically necessary contact lenses, now that the 92072 code has replaced it for medical plans?
A: First, with the exception of keratoconus, the 92072 code did not replace the 92313 code. The distinction is true whether we are talking about VCP MNCL benefits or medical plan MNCL benefits. The rules are the same. There are still many instances where a scleral lens is the correct choice for the patient, and they do not have keratoconus. In those cases, use the 92313 CPT code.
Q: Can we charge a different fee for the fit code 92310?
A: The Relative Value Units (RVUs) for all CPT codes are contemplated for the “average work” required to provide the service. If the amount of work is more or less than that, there are modifiers that can be used to increase or decrease the amount of reimbursement.
It is illegal to charge Medicare or Medicaid more than you charge other carriers or the patient. They don’t care if you charge Medicare or Medicaid less. Overbilling state and federal programs is a criminal offense. Overbilling private payors is a breach of contract tort.
If you need more than one fee for a procedure, then you can use the -22 and -52 modifiers to charge more or less, respectively. The -22 modifier will increase the fee, when documented in writing, up to 150%, depending on carrier adjudication, while the -52 modifier will automatically reduce the fee to 50% of the charge.
Q: How are you setting different fees for different types of fits with 92310? You explained how to go from sphere to bi-toric, but in practice we have different fees for all lens types (sphere, torics, specialty torics, bi-toric, multifocal, GP, soft, etc.). How can you specify the same price tier you set up for self-pay with only one code and one modifier?
A: You can’t. You are trying to think of these charges as “fitting fees.” You have to stop thinking like that. The Limiting Charge for a CPT code is designed for the “average” work RVU. If the service is less demanding than average, then you add the -52 reduced services modifier. If it is more complex, then you add the -22 unusual services modifier along with the letter of explanation.
Q: Does the patient have to pay a copay if you bill 92135 if you change the power of a medically necessary lens?
A: You bill applicable copayments and unmet deductibles according to the plan the patient has and the provider contract that you signed for the payor.
Q: Can you bill 99 or 92 intermediate – and then another 92313 if you change a parameter of a scleral lens, assuming you billed 92313 initially?
A: You can bill another 9231x code if the change is substantial and not an “incidental” revision. The billing of an E/M or a general ophthalmological code depends on the circumstances, but the preamble to the 9231x codes states that an examination is not part of the 9231x service.
Having said that, it is hard to justify these additional services when performed closely following the original examination services unless there is clearly documented evidence of substantial change.
Q: If I successfully fit a patient in a scleral contact lens for keratoconus and bill a 92313, then see that patient back one year later, can I bill another 92313 if I make a few parameter changes to the lens?
A: You can bill a 92072 code only for the diagnosis code of keratoconus. Changes thereafter are billed using E/M service codes. Some coding consultants believe that the 92072 code is billed only once per lifetime per provider. However, others – including myself – believe that the “initial fitting” means the first visit of a discrete fitting interval.
Q: I’ve heard the -22 modifier is limited to use for surgery only. Is that true?
A: On March 4, 2013, Palmetto GBA, which is one of the fiscal intermediaries, issued a Local Carrier Determination (LCD) for Jurisdiction 1 that limits the -22 modifier to procedures that have a 000, 010, or 090 day global period. The global limitation is for surgical codes.
The problem with that is, it directly contravenes the NCD of CMS and 2013 CPT text for the -22 modifier.
The 2013 CPT text for the -22 modifier reads:
-22: Unusual Procedural Services “When the Work Required to Provide a service is substantially greater than typically required, it may be identified by adding modifier -22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).”
NOTE: This Modifier Should Not Be Appended to E/M Services
As, you can see, the CPT text of the -22 modifier talks about “service,” not “surgery.”
On March 8, 2013, CMS issued a revision to chapter 12 of the Medicare Claims Processing Manual. So, it is totally up to date. Contained in Chapter 12 is 20.4.6. It was last modified in 2003, and since the 2013 revision has just been issued, no change will be made to that provision this year. 20.4.6 reads:
20.4.6 – Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”)
(Rev. 1, 10-01-03)
The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances, based upon review of medical records and other documentation.
So blanket statements like “The -22 modifier applies only to surgical codes” is inaccurate. What rules is what is in the rules. If I were in Jurisdiction 1, I would appeal Palmetto’s LCD to CMS as directly contravening §12, 20.4.6 and 2013 CPT. I have found several providers in that Jurisdiction that have issued guidance reflecting the change at Palmetto GBA.
Q: 22 modifier: when you say submit documentation, is this a letter to the carrier, or is it in the patient visit record?
A: The -22 modifier requires a letter of justification that must reach the payor, and it must contain a rationale for the “substantial” extra work and a description of that extra work.
Q: So you cannot use the -22 modifier on a 99 code, but can you use it on 92 codes?
A: No, it is the other way around. The -22 modifier can be used only on the E/M codes.
IV. Scleral Lenses
Q: Do the V2530 and V2531 codes have different reimbursement levels? Is it wrong to use the V2531 for all scleral lenses?
A: The V2530 is for the impermeable scleral lens made from PMMA. Never use this code. Always use the V2531 for scleral lenses.
Q: Can you bill an anterior OCT code for fitting and later for management of the scleral lens?
A: If the images are medically necessary, in that they are indicated by the history, are rational to the prescribing of the lenses, are ordered in writing, are reviewed and interpreted – and the results affect your medical decision-making – then one can establish medical necessity for any service at any time, barring limits placed on interval and diagnosis in a local or national carrier determination.
Q: If you bill VSP for an initial fit of a scleral contact lens and the lens breaks or is lost three months later, can you utilize any remaining amount from that plan not previously used, or is it an all-or-nothing benefit?
A: No. The necessary contact lens benefit under VSP is a one-time-per-defined-period benefit regardless of whether or not you reach the maximum.
V. What are Medically Necessary Contact Lenses (MNCLs)?
Q: Our medical compliance office has also suggested that we (and probably all offices, I am presuming) should have our own definition of MNCL. I doubt that few if any practitioners have a written definition of MNCL that they could pull out, so if not, how do you know what MNCL is?
The “I know it when I see it” explanation does not really hold up in an audit. Some third-party entities have them, but many do not, and state Medicaid or similar may not have specific definitions. So if asked, we need to be able to provide it and say this is our definition.
A: There are standard definitions of medical necessity that apply contractually to providers when billing the payors and the VCPs that must be followed. Making up your own definition of medical necessity is not appropriate. The standard definition of medical necessity that HHS, all of the states, and with slight modifications to exclude non-FDA stuff, all of the private payors, is the 1999 AMA Definition of Medical Necessity.
Contracted providers are not free to make up their own definition of medical necessity, and any such definition should be discarded as proof of willful intent to violate the terms of the payor contracts. For most private payors and all of the VCPs, a list of approved diagnoses is available in their respective policies regarding medically necessary contact lenses.
Q: Would using a specialty contact lens with someone with high astigmatism and not keratoconus be a medically necessary contact lens?
A: Frequently, yes.
VI. Other Coding Questions
Q: If I am fitting a keratoconic patient with hydrophilic lenses, would I use the material code (HCPCS) V2520?
A: The HCPCS Code, V2520, is the spherical non-extended wear hydrogel. Unless that is the lens you are using, I would choose a different code. The V2521 is the soft toric code, and the V2523 is the extended wear code. If the material is approved for extended wear, then the V2523 code is better.
Q: What about the SO515 – liquid bandage device as opposed to V2627 to bill a scleral for OSD/dry eye?
A: The “S” Codes are temporary codes, and should never be used when a permanent code is appropriate.
Q: What V code do I use for the reverse geometry soft lens RevitalEyes or the Kerasoft IC lens? In particular, with VSP. Is this considered a v2599 code or v2521?
A: I recommend using the V2599 code (“Contact Lens, other type”), accompanied by a letter of medical necessity to justify the extra charge.
Q: How do you justify a 99205 level with a keratoconus diagnosis?
A: The diagnosis doesn’t matter. There is a whole appendix to CPT that instructs the provider on how to bill the E/M service levels correctly.
Q: Is code 92072 unilateral or bilateral? I bill this unilateral, and Veterans Affairs pay this as unilateral, but other insurance pay as bilateral.
A: The 92072 was originally meant to be unilateral. CMS decided it was bilateral, and some payors followed suit to reduce their reimbursements. It is a carrier decision now.
Q: What V codes do you use for hybrid lenses?
A: V2599, along with a letter of medical necessity.
VII. Advanced Beneficiary Notifications
Q: What about Advanced Beneficiary Notifications (ABNs)?
A: ABNs are required by Medicare for services, medical equipment, or supplies denied in advance (more info here). That is no longer true for keratoconus, because they are now covered services. If prescribing for scleral shells, NCD 80.5, Aphakia, NCD 80.4, or keratoconus, these services are covered, and an ABN is not required. For all other reasons for prescribing MNCLs to Medicare-qualified beneficiaries, an ABN, and the proper reporting of the services and materials provided are required (more info here).
VIII. Miscellaneous Reimbursement Questions
Q: When can we require a patient to pay the difference between what we charge and what insurance pays?
A: The terms of all payment relationships are contained in the provider contract that is executed between the payor and the provider. Before signing any contract, it is imperative that the provider knows what the cost of each given service is so that they can compare what the potential recovery is to the cost to see if the plan makes rational sense to their practice. If the comparison is adverse to the practice, then don’t sign the contract.
For Medicare, accepting assignment, which most of us do, means that you cannot balance-bill the patient for covered services. That does not speak to non-covered services. However, an ABN must be in place before.
One problem that we currently have is that some covered services are not being paid. That makes it challenging for us. We cannot bill the patient directly for covered services and materials, but the payors are not compensating us. This problem will have to be solved quickly.
The rules about when you can bill a patient – before or after payor adjudication – are a term provision of the contract. Medicare forbids prior billing and reimbursement for covered services. Aetna and BCBS also forbid the provider from billing the patient first, and then seeking reimbursement for the patient. Again, check the provisions of the provider/payor contract for specific details on billing. Sometimes, as is the case in Medicare, there is a manual that must be consulted.
- The new Medicare code for keratoconus covers the fitting and materials. But if the reimbursement does not even cover the cost of the lens material, can we bill the patient for the difference?
- If we know insurance covers some fit and material fees, can we collect all the fees up front and ask the patient to submit to insurance for reimbursement?
Q: How to handle billing with non-refundable lenses? For example, I use a specific corneal GP lens for a keratoconic, but after a few adjustments to the fit, I decide that I want to try a scleral lens. I can’t get a refund for the corneal lenses. How do you suggest billing these lenses to the insurance or patient?
A: Develop a policy that states that the patient pays for anything you do. Put this in your brochure, and discuss it with the patient BEFORE you prescribe for them. That way, if you use a non-returnable lens, then the patient needs to know that you might, and therefore they might, have to pay for another lens. If their insurance payor will cover only one lens, but you use two, then so be it.
A really important concept for you to grasp is that it is not your fault that they need these really expensive specialty lenses, and therefore it is not your responsibility to subsidize their lens management expenses. While the expenses may burden the patient, it is not your responsibility to take that on for yourself.
It is your responsibility to create efficient patient processes in your office and to become an expert, so that you minimize the cost to the patient and the payor by using fewer lenses to make things rights as quickly and with as few lenses as possible. If you have to change gears to a different lens, do so, and charge the patient accordingly, but do not eat the lens costs yourself.
Q: How do you deal with knowing whether the lens will improve VA two lines or more without doing the fitting part first? What if you perform all of the work and you don’t get the visual improvement?
A: You need to trial the lens on the patient to see where you are. Whether or not a service is covered speaks only to who pays for the service, not whether or not you perform the service.
Q: When you submit the claim electronically, how do you include the letters of medical necessity and other documentation?
A: Letters of medical necessity can be scanned and e-mailed to the EDI or the payor, or they can be mailed to the payor.
Q: What about contact lenses for cosmetic masking of aniridia, or other disease-related problems for which a custom cosmetic lens helps with photophobia or with the psychological status of the patient?
A: These lenses are medically necessary for most carriers. However, VSP and EyeMed exclude these lenses. So the non-covered services of prescribing the lenses and the lens costs are billed directly to the patient.
Q: Do you recommend billing a global fee for follow-up visits instead of E and M codes?
A: No. The text, the pre-text instructions, and the sub-text instructions for the 92071, 92072, and all of the 9231x codes demand that you bill E/M or general ophthalmological codes, depending on the code used.
Q: How do you bill when “fitting” is one DOS but patient doesn’t receive the lenses until a later DOS, BUT for vision plans the V253x code makes the fitting code medically necessary also, so they have to be billed together even though they are on different dates?
A: Services and material costs are billable at the time ordered, not at the time delivered.
Q: When you see a patient back for a follow-up visit, do you charge the patient their copay every time?
A: Yes, if that is what is required of you by the participation agreement between you and the payor.
Q: Does the OD have to perform the test to bill technical only or can it be performed by a technician? If the technician can do it, does the OD have to sign off on the accuracy?
A: A technician may perform a test for the -TC component. Appending a CPT code with the –TC modifier is asking for reimbursement for having used your equipment. The decision by a provider to warrant the validity of the test is a personal decision.