Understand when and how to code for lenses used for therapeutic purposes
A contact lens (CL) usually contains an optical correction for ametropia for use instead of eyeglasses. However, some contact lenses are designed as a protective bandage for an eye that has corneal disease. Except for post-cataract lenses, CLs prescribed for refractive errors are not reimbursed by Medicare. However, bandage contact lenses (BCL) used for therapeutic purposes (e.g., to promote healing or for pain management) are covered by Medicare, so long as the lens is FDA approved as a therapeutic BCL.
WHAT IS THE PROPER USE OF CODE 92071?
The professional service of the fitting is identified on the claim by CPT 92071. Use this code to identify the fitting each time it is performed. Note that the term “lens” in the descriptor is singular, not plural, which denotes a “unilateral” service, so reimbursement is per eye. Separate payment is made for the fellow eye if a patient requires two therapeutic CLs.
An additional point is that some people have advocated 99070 for the supply of the contact lens, but for Medicare, this has status indicator “B,” which means it’s bundled. Other payers may have different rules denoting CPT 92071 as a “unilateral” service, so reimbursement is per eye. Separate payment is made for the fellow eye if a patient requires two BCLs.
In 2021, the national Medicare Physician Fee Schedule allowable for 92071 is $37.00 in-office and $33.00 in a facility. Local wages indices in each area adjust this amount. Other payers set their rates, which may differ significantly from the Medicare published fee schedule.
WHEN WILL MEDICARE COVER A BANDAGE LENS?
Medicare’s National Coverage Determination (NCD) §80.1 describes covered uses of BCLs as:
“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 ectasia, Mooren’s ulcer, anterior corneal dystrophy, neurotrophic keratoconjunctivitis, and for other therapeutic reasons.”
The term “hydrophilic contact lens” does not include corneal collagen shields as BCLs, and several Medicare policies preclude coverage of collagen lenses.
The NCD’s Indications and Limitations of Coverage has this to say about reimbursement for BCLs:
“Payment may be made under §1861(s)(2) of the Act for hydrophilic contact lens approved by the Food and Drug Administration (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 critical, but what does it mean?
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 person-al, professional services in the course of diagnosis or treatment of an injury or illness.” In this context, the service is 92071 (fitting of contact lens, etc.), so making a separate claim for the BCL supply is inappropriate. Some Medicare contractors also treat 92071 as bundled with an exam, and will pay for an exam or bandage lens but not both.
HOW OFTEN CAN 92071 BE BILLED?
Medicare will often deny claims when the frequency of a service is excessive in their view. If the use of 92071 becomes frequent (e.g., >1 per month), it may be appropriate to collect payment from the patient in the event Medicare denies the claim for being too frequent.
Get the patient’s signature on an Advanced Beneficiary Notice (ABN) before dispensing the BCL, indicating that the patient accepts financial responsibility in the event of a denial. The ABN must include a brief description of the BCL and why a denial from Medicare is expected, such as “Medicare does not cover more than one replacement lens per month”; it cannot simply be a statement that Medicare won’t pay.
CPT code 92071 is probably under-utilized due to the confusion related to coverage policy and billing. Take the time to familiarize yourself with the coding guidelines, and bill when appropriate. OM
