Article Date: 6/1/2003

coding q & a
Coding Bandage Contact Lenses
Learn how and when to code for these therapeutic devices, plus more.
By Suzanne Corcoran, C.O.E.

Q What is a bandage contact lens?

A contact lens usually contains an optical correction for ammetropia for use in lieu of eyeglasses. Except for postcataract lenses, Medicare doesn't separately reimburse contact lenses prescribed for refractive errors. However, it does cover bandage contact lenses used for therapeutic purposes. The Food and Drug Administration (FDA) approves only certain lenses as bandage lenses.

Current Procedural Terminology lists 92070 (fitting of contact lens for treatment of disease, including supply of lens). Note that this is per eye. Medicare's physician fee schedule defines this service as unilateral and indicates that it reimburses 100% of the allowed amount for each eye. When submitting a claim for 92070, use modifier RT, LT or 50 (both eyes) where applicable. The 2003 national Medicare unadjusted allowable fee for 92070 is $61.41.

Q When will Medicare cover a bandage lens?

Medicare's National Coverage Determinations (NCDs) describes covered uses of bandage contact lenses: "Some hydrophilic contact lenses are used as moist corneal bandages for the treatment of acute or chronic corneal pathology, such as bullous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, corneal edema, descemetocele, corneal ectasis, Mooren's ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis and for other therapeutic reasons." The term "hydrophilic contact lens" doesn't include corneal collagen shields as bandage contact lenses and several Medicare policies specifically preclude coverage of collagen lenses.

The Indications and Limitations of Coverage listed in the NCD provides special instructions about reimbursement for bandage contact lenses. It states, "Payment may be made under §1861(s)(2) of the Act for hydrophilic contact lens approved by the FDA and used as a supply incident to a physician's service. Payment for the lens is included in the payment for the physician's service to which the lens is incident." The "incident to" phrase is key, and the Medicare Carriers Manual §2050.1 defines "incident to" services: "Incident to a physician's professional services means that the services or supplies are furnished as an integral although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness." In this context, the service is 92070 (fitting of contact lens, etc.), so it's not appropriate to make a separate claim for the bandage contact lens supply. Some Medicare carriers also treat 92070 as bundled with an eye exam and will pay for an exam or bandage lens but not both.

Watch out

Medicare will often deny claims if the frequency of a service is excessive in its view. If the use of 92070 becomes frequent (e.g., >one each month), it may be appropriate to collect payment from the patient in the event Medicare denies your claim. Get the patient's signature on an Advanced Beneficiary Notice (ABN) before dispensing the lens, indicating that the patient accepts financial responsibility in the event of a denial. The ABN must include a brief description of the bandage contact lens and the reason why you expect a denial from Medicare. For example, "Medicare doesn't cover more than one replacement lens per month."

During 2000, Medicare paid about 18,000 claims for 92070 out of a universe of approximately 24 million eye exams. CPT code 92070 is probably underused because of the confusion related to coverage policy and billing.

Suzanne Corcoran is vice president of Corcoran Consulting Group.  Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.


Optometric Management, Issue: June 2003