Coding for medically necessary contact lenses requires work on the back end

Among the hundreds of questions OM received to the Q&A issue (Dec.), multiple questions we received were related to: how to code for medically necessary contact lenses. As this issue is our contact lens issue, here, I’ll answer this question, outlining my best practices for doing so.

GATHER THE INFORMATION

Several insurance companies provide coverage to patients for medically or visually necessary contact lenses. For some plans, these lenses are covered in full for patients whose conditions meet the established criteria. The criteria may be different for each plan.

To successfully achieve reimbursement for this patient population, the first steps to take are to find these requirements on each one of your partners’ websites and print them. Be certain this information is accessible, for example by making copies and distributing them, to each provider and billing staff member.

ANALYZE THE PLAN DATA

A few questions to ask as you are scheduling, documenting and offering services for these patients:

1. Is the patient eligible for services and materials on the date of service you have chosen?
2. What is the copay for services and materials?
3. Can the practice balance bill the patient for amounts not covered by the insurance and lower than the practices usual and customary fee?
4. What diagnosis has been documented in the record, and is it a covered diagnosis? Are you using the correct code on the claim for the diagnosis based on the insurance requirements?
5. What are the allowed amounts for the exam and materials based on the diagnosis and the chosen type and manufacturer of lenses?
6. Did your team remember to include the information on the type and manufacturer of the lenses?
7. What documentation requirements does the insurance company have for this exam to ensure coverage?
8. If the patient requires piggyback lenses, will both lenses be covered and what is the coverage?
9. Is there a requirement for the number of units for the contact lens materials on the claim?

Be aware that most insurance plans will default to the lowest paid materials if the required information on the claim submitted is missing or incomplete. Additionally, a few insurance companies require prior authorizations for medically necessary contact lenses, so be certain to know each insurance company’s requirements and policies prior to moving forward with the contact lens examination and before providing materials.

EDUCATE YOUR TEAM

The good news about medically necessary contact lenses is that the information needed to be successful in the examination, documentation and billing is readily accessible. The bad news is that the requirements can be different for each insurance company. To ensure success for the practice and the patient — and a seamless experience for both — plan ahead and educate your team. OM

CODING QUESTIONS

 

 

I answered a few of your other coding questions in the Q&A issue in December. Find that article at bit.ly/OM1220Coding . You can also email me, and I will do my best to answer your questions in future Coding Strategy columns.

DR. JASPER practices in West Palm Beach, Fla. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.