ReVision Optometry is the first practice in San Diego designed from the ground up to provide services to patients with visually necessary and medically necessary contact lens needs. The firm is independently owned and managed by Brian Chou, OD, FAAO, FSLS. Dr. Chou previously founded and ran a contact lens clinic in northern San Diego, 4S Ranch, which was acquired by a private equity subsidiary in 2017. More than 125 ophthalmologists referred their patients visually and medically requiring contact lenses for special treatment. To make an appointment, call 619-299-6064 or visit revisionoptometry.com. Keratoconus, when the vision of the limb in one or both eyes cannot be corrected 20/25 with standard spectacle lenses. 1Harmon H, Caswell J. Vision Insurance FAQ: Frame, Lens and Contact Lens Benefits. VSPdirect.com website Refine and modify In many situations, “random lens revision during the training period” and “with medical supervision of fit” are performed at the first visit after contact lens delivery. Once the correct vision and comfort criteria are met and you have ordered the final lenses or provided the patient with their contact lens prescription, the patient may be considered suitable for contact lenses and the service period for that particular code has expired. In case of complications, the best way to bill for doctor visits is to use the ophthalmic (9201X) or established assessment and management (9921X) codes, as you are following or treating an eye condition and do not perform contact lens examinations. No consensusThe definition of medically necessary contact lenses should be clear now, but continues to be analyzed, segmented and redefined by third-party providers.
Practitioners may also have to bear some of the blame, as some are unable to determine and document the actual medical need for a contact lens in relation to certain conditions. From the payers` perspective, there has been waste and abuse, which has led to further scrutiny and tightening of payer policy. For this reason, medically necessary contact lenses have different definitions depending on the wearer who provides the benefits. Here are some examples: To check what VSP thinks is medically necessary, log in and scroll down to Visually Necessary Contact Lenses (LCN) under “Plans and Coverage” in the “Manuals” section.5 Some eye conditions can only be corrected with contact lenses. These include: The supply of contact lenses can be declared as part of personalization. It can also be reported separately using the appropriate delivery code. The prescription of contact lenses includes the indication of optical and physical properties (such as power, size, curvature, flexibility, oxygen permeability). It is not part of the general ophthalmic services.
All requests for medically necessary contact lenses must be submitted by the network provider for review and approval by our Medical Director before a service request is processed. “The contact lenses required are a designation based on criteria established by a third-party payer, such as Vision Services Plan (VSP) or EyeMed vision care. Each plan has different qualification criteria. The approval process involves the doctor`s office submitting and certifying specific documents after a patient`s eye exam. When contact lenses are approved as required, the cost of lenses and services is covered, sometimes in full. This can save patients hundreds or even thousands of dollars each year. 92072: Contact lens placement, initial placement.8 Since this is a two-sided code, be sure to report documents in addition to this code using Code 99070 or Common Procedures for Health Care (HCPCS) Level II material code. According to the CPT: “For subsequent adjustments, contact the assessment and care service or the general ophthalmology services.” For each subsequent visit, use a 9921X or 92012 code to track the keratoconic cornea – remember that you are following the keratoconic cornea and the contact lens is only the paradigm of treatment.
Successful long-term lens tracking is reported as part of a general ophthalmic service. (92012 ff.) The supply of contact lenses can be reported as part of personalization. It can also be reported separately using the appropriate delivery code. Almost all types of contact lenses can be considered necessary. For example, lenses can include various replacement plans ranging from daily (disposable), biweekly, monthly, quarterly disposable lenses to annual replenishment. The necessary contact lenses can also include various types of designs, including soft, toric (for astigmatism), piggyback, multifocal and monovisional, hybrid, rigid corneas, rigid scleral and prosthetic lenses. The type of contact lens prescribed does not determine whether it is necessary. The decisive factor is whether there is a specific eye disease that meets the vision plan criteria for the necessary contact lenses. That is, a disproportionate number of patients who wear contact lenses for medical eye diseases have custom-made lenses, including rigid scleral contact lenses.
Cracking the code According to the CPT section, which covers contact lens adjustments: “Contact lens fitting includes the instruction and training of the wearer and notes: Visually necessary contact lenses are generally not covered for patients who have undergone elective cosmetic eye surgery (e.g., LASIK, PKR, radial keratotomy). However, postoperative concerns such as ectasia, scarring, and corneal irregularities that cause vision problems that require correction with contact lenses to enable functional vision are covered by the NCL benefit as long as patients meet the NCL criteria. This puzzle is best illustrated by billing and coding medically necessary contact lenses. For patients with severe refractive error or anisometropia, it is important to include the prescription for glasses in the laboratory prescription so that the insurer can verify if the condition meets the medically necessary requirements. Fitting specialized contact lenses isn`t always as easy as fitting traditional contact lenses, but expanding your skills can open up a wider and more diverse patient base.