If you’d like to insulate yourself from the commodity-based world of disposable contact lens margin erosion, a specialty contact lens practice is one effective way to do so.

Specialty lenses may not get as much attention as other practice-building opportunities, but I believe this area of optometric practice has tremendous potential for growth. Yet it’s also a hotbed of frustration for many practitioners—especially given the confusion and apprehension surrounding medical coding and reimbursement.

Generally, when a practitioner considers fitting a patient in a specialty contact lens, it is typically predicated on the presence of a specific medical condition or refractive complication caused by an existing corneal condition. Ocular surface disease (OSD) is an emerging area of both wellness and medical care within many practices today.

Building a specialty contact lens practice can be both extraordinarily satisfying and challenging. So, my goal is a simple one: to make coding for and getting reimbursed for specialty contact lenses the easiest part of your very specialized practice.

Back to Basics
Before getting into specific codes, it’s necessary to review some basics. In order to know how to properly document your medical record and to use the correct Current Procedural Terminology (CPT) code to describe the appropriate services provided, it is important to understand and keep up to date with the current definitions of the contact lens fitting codes as described in the CPT.

Just because you are fitting contact lenses doesn’t mean that you can forget or ignore the fundamental concepts of medical necessity, or the requirements of the chief complaint in your medical record.

As mentioned earlier, because you will often be working with a disease process or a medical condition, you must be very familiar with the requirements for the appropriate use of the 920XX and 992XX codes for your office visits that get coded in addition to your contact lens services.

The CPT has the following to say about contact lens fitting: The prescription of contact lens includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, gas permeability). It is not a part of the general ophthalmological services. The fitting of contact lenses includes instruction and training of the wearer and incidental revision of the lens during the training period. Supply of materials may be reported as part of the service of fitting, or may be reported separately using the appropriate supply codes. Follow-up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service (92012). 

Now that we’ve got the basics covered, let’s dive into the handful of CPT codes that cover the fitting of contact lenses.

Traditional Contact Lens Fitting Codes1
These are the bread-and-butter codes used for routine contact lens services.

• 92310: Contact lens fitting. This is defined by CPT as the “prescription of optical and physical characteristics of and fitting of a contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.” A 92310 should be charged for the fitting of contact lenses, and also encompasses services up to the point at which you would issue a contact lens prescription. This code does not include contact lens follow-up care after the lenses have been dispensed.

This code is charged every visit in which a new lens is placed on a patient’s eye, or when the fit is altered. Incidental revisions, such as power changes without altering the fit, are not billed as a new fitting. Keep in mind that the modifier -52 should be used if fitting only one eye; this is a change that was implemented in 2011, replacing the –RT or –LT modifier that was used prior to that date.

• 92311: Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye.

• 92312: Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes.

• 92313: Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens.

Codes for Therapeutic Uses of Contact Lens
Use these codes when the service provided includes an element of medical care.

• 92071: Fitting of a contact lens for treatment of ocular surface disease. Please be sure to report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code. It is important to keep in mind that this is a unilateral code.

• 92072: Fitting of a contact lens for management of keratoconus, initial fitting. Please report materials in addition to this code, using either 99070 or the appropriate HCPCS Level II material code. This originally was a unilateral code, but in mid-2012 the CMS & AMA opinion stated that this code would be changed from unilateral to bilateral.

When dealing with keratoconic fittings, please keep this specific quotation of the CPT in mind: “For subsequent fittings, please use either the 9921X or 9201X codes.” Again, it is important to note that in scenarios such as this you are not following the contact lens; you are following the keratoconic cornea—the contact lens is a treatment option.

Refining and/or Modifying Your Fit
In most cases, “incidental revision of the lens during the training period” and “with medical supervision of adaptation,” are accomplished at the first post-contact lens dispensing visit.

Once the proper vision and comfort criteria are met, and you have ordered the final lenses and provided the patient with their contact lens prescription, the patient can now be considered fit for the contacts.

Again, should complications arise, the most appropriate way to bill for office visits is by using the established patient ophthalmologic (9201X) or evaluation and management (9921X) codes. Keep mind that with many (if not most) specialty contact lens fits, you are following a corneal or OSD state—not the contact lens. Many practitioners are giving away thousands of dollars per year by unintentionally including this “free care.”

• 92325: Modification of contact lenses. CPT defines this code as “modification of contact lens (separate procedure), with medical supervision of adaptation.” This applies when you polish or modify the parameters of an RGP lens using a modification instrument. This is a unilateral service. If done bilaterally, use modifier -50, change your units to two and double your price to indicate it was performed on both eyes.

• 92326: Replacement of contact lens. This covers the professional administrative services for ordering a replacement lens. Also, remember to bill for the lenses separately using the appropriate level II HCPCS V-codes.

Additionally, never consider a fitting fee to be a global, year-long obligation to provide unlimited service to the patient at no charge. If you refit a patient, and it is not just an “incidental revision of the contact lens,” then another fee for 92310, 92311, 92312 or 92313 would be an appropriate code to bill, along with the appropriate materials V-code or Healthcare Common Procedure Coding System (HCPCS) code for lens supply.

Additional ophthalmic testing and procedures are often necessary in a specialty contact lens practice. Examples may include:

• Corneal topography (92025): This is probably the best way to monitor progression of keratoconus or other corneal disorders—especially using the change analysis features of the instrument.

• Anterior segment photography (92285): Use this to follow progression of endothelial folds, scarring or other similar complications.

• Endothelial photography and cell count (92286): This is great for following degenerative changes to the endothelial cell layer resulting in therapeutic decisions. Be sure to pay close attention to National Coverage Determination (NCD 80.8) for additional rules and regulations regarding use of this code.

• Pachymetry (76514): This describes the determination of corneal thickness by ultrasound. Use this to monitor progressive thinning of the corneal apex. Keep in mind that the once-a-lifetime limitation associated with this code only applies with respect to the diagnosis of glaucoma and corneal use, and is dependent upon the medical necessity that you establish in the medical record.

“Does My Insurance Cover This?”
Insurance benefits for specialty contact lenses vary greatly. Some managed vision care plans have benefits that their members can purchase that will cover specialty lenses; however, not all policies or benefits are the same.

Remember to consult your local carriers’ medical policies as well as your provider agreement for specifics on specialty contact lens coverage. Be mindful of patients who haven’t purchased coverage for medically necessary contact lenses—you can’t “create” coverage if it simply doesn’t exist.

So, if there is an exclusion for all contact lenses—or no coverage at all—tell the patient at the initial visit what the total charges will be. Explain to the patient exactly what the fee does and does not cover, including lens exchanges and office visits.

Once you’ve discussed it with the patient, use an Advanced Beneficiary Notice (ABN) form to properly document this disclosure. An ABN is required for Medicare claims (and is accepted by other carriers), and is the best method to inform patients of suspected out of pocket costs.

When completing the ABN form, use the appropriate modifier -GA, -GX, -GY, or -GZ, appended to the CPT or HCPCS code. This will indicate to the carrier that the patient has received appropriate disclosure of personal financial responsibility and has attested to that with their signature on the ABN form.

Building a specialty contact lens practice can be a very rewarding endeavor. Employing all the cutting-edge technology available to us, and our expertise in both optics and the ocular surface, optometry can serve our patients very well by providing the best patient outcomes while keeping our practices safe and profitable.

1. Current Procedural Terminology (CPT) 2014. American Medical Association, p. 539.