Medically/Visually Necessary Contact LensesAaron Wolf, O.D.November 14, 2012

What Are Visually Necessary Contact Lenses?

• Medically and visually necessary contact lens services are covered in full or in part by third party payers for those patients whose visual experience and function is significantly improved through the use of contact lenses rather than spectacle lenses

• Some insurances additionally offer full coverage of spectacle lenses (not frames) to wear over medically necessary contact lenses

• Defined by insurance manual and policies. Subject to change at any time (and often does!)

Benefits of Medically Necessary Contacts

• Improved visual acuity• Improved peripheral vision• Reduced asthenopia• Reduced suppression• Better option for face or head deformity• Better option for those with metal allergy• Others?

Insurance Plans• Good• VSP Signature• VSP Choice

• Okay• EyeMed

• Not So Good• Superior• Others?

Verify if patient’s eligibility to start on January 1st vs. Date of Service of last exam.

Patient’s copay may change when submitting for medically necessary contact lens services.

Criteria for Eligibility• Depends on insurance company• Check insurance manual regularly and be alert to policy

update notifications

**This presentation focuses on VSP criteria from here on.**

Visually Necessary Criteria• Nystagmus• Anisometropia of at least 3.00 D in any meridian based on

spectacle prescription• High ammetropia at least -10.00 D or +10.00 D in either eye in

any meridian based on spectacle prescription

HCPCS Annual Replacement (1-2 lenses)

Planned Replacement (3-360 lenses)

Daily Replacement (361+ lenses)

V2510 (sphere GP) $450 - -

V2511 (toric GP) $650 - -

V2512 (bifocal GP) $750 - -

V2513 (EW GP) $500 - -

V2520 (sphere SCL) $375 $525 $750

V2521 (toric SCL) $525 $650 $810

V2522 (bifocal SCL) $537 $650 $1,000

V2523 (EW SCL) $475 $600 $625

V2531 (scleral GP) $987 - -

V2599 (hybrid) $900 $1,250 -

Piggyback $900 $1,250 -

Visually Necessary Specialty Criteria

• Keratoconus • Irregular astigmatism• Corneal transplant• Corneal opacities• Aphakia• Corneal ulcers• Localized corneal neovascularization• Deep corneal neovascularization• Corneal pigmentations and deposits• Corneal edema unspecified• Bullous keratopathy• Folds in Bowman’s membrane• All corneal degenerations• All corneal dystrophies• Corneal deformities and ectasia• Corneal disorder due to contact lens

(Duh!!)• Congenital anomalies of corneal size

and shape• Alkaline chemical burn of cornea and

conjunctival sac• Mechanical complication due to

corneal graft• Pseudophakia

Visually Necessary Specialty Criteria

Some are so special…they’re hilarious!• 871.0 - Ocular laceration without prolapse of intraocular

tissue• 871.1 - Ocular laceration with prolapse or exposure of

intraocular tissue• 871.5 - Penetration of eyeball with magnetic foreign body• 871.6 - Penetration of eyeball with (nonmagnetic) foreign

body• 871.9 - Unspecified open wound of eyeball

HCPCS Annual Replacement (1-2 lenses)

Planned Replacement (3-360 lenses)

Daily Replacement (361+ lenses)

V2510 (sphere GP) $657 - -

V2511 (toric GP) $800 - -

V2512 (bifocal GP) $900 - -

V2513 (EW GP) $825 - -

V2520 (sphere SCL) $500 $650 -

V2521 (toric SCL) $679 $804 -

V2522 (bifocal SCL) $750 $863 -

V2523 (EW SCL) $650 $775 $800

V2531 (scleral GP) $2,300 - -

V2599 (hybrid) $1,050 $1,400 -

Piggyback $1,050 $1,400 -

Profit Margins Breakdown

(Coming Soon!)

Topography• (Examples here)

Contact Lens Fitting• 92310 – Prescription of optical and physical characteristics of

and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia

• Level 1? Level 5? Level 14? Level 42? Quit making up numbers! No such thing as levels within a single CPT code.

• 92310 considered non-covered service. Pricing based on U&C fees per complexity of service.

• The contact lens doesn’t determine the fee. The EYEBALL determines the fee!!

Contact Lens Fitting• Contact Lens Services• 92311 – corneal lens for aphakia, 1 eye• 92312 – corneal lens for aphakia, both eyes• 92313 – corneoscleral lens

• Special Ophthalmological Services• 92071 – Fitting of contact lens for treatment of ocular surface

disease• 92072 – Fitting of contact lens for management of keratoconus,

initial fitting

Example #1• 40WM• RFV: poor vision at distance and near, long-standing• Inferior steepening and “hot spot” on topography• MR BCVA 20/30 OD, 20/25 OS

• Dx?• Billing?

Example #1• Dx: Keratoconus, presumed stable condition• Billing option 1:• To medical insurance

• 92004/14 – 371.61 Keratoconus, stable• 92015 - 371.61 Keratoconus, stable• 92025 - 371.61 Keratoconus, stable• 92132 - 371.61 Keratoconus, stable• 76514 - 371.61 Keratoconus, stable• 92286 - 371.61 Keratoconus, stable

• To VSP• 92310 Specialty Maximum for preferred contact lens - 371.61

Keratoconus, stable

Example #1• Dx: Keratoconus, presumed stable condition• Billing option 2:• To medical insurance

• 92025 - 371.61 Keratoconus, stable• 92132 - 371.61 Keratoconus, stable• 76514 - 371.61 Keratoconus, stable• 92286 - 371.61 Keratoconus, stable

• To VSP• 92004/14 – 371.61 Keratoconus, stable• 92015 - 371.61 Keratoconus, stable• 92310 Specialty Maximum for preferred contact lens - 371.61

Keratoconus, stable

Example #1• Dx: Keratoconus, presumed stable condition• Billing option 3, if no VSP insurance:• To medical insurance

• 92004/14 – 371.61 Keratoconus, stable• 92015 - 371.61 Keratoconus, stable• 92025 - 371.61 Keratoconus, stable• 92132 - 371.61 Keratoconus, stable• 76514 - 371.61 Keratoconus, stable• 92286 - 371.61 Keratoconus, stable• 92310 or 92313 - 371.61 Keratoconus, stable• 92072 - 371.61 Keratoconus, stable

Example #2• 55HF• “fuzzy” vision, glare at night• MR BCVA 20/20 OD & OS• Normal topography• Mild irregular appearance of posterior cornea on slit lamp• Specular microscopy shows few black spots, inconsistent size

of cells

• Dx?• Billing?

Example #2• Dx = endothelial guttata/endothelial corneal dystrophy• Billing option 1:• To medical insurance:

• 92004/14 – 371.57 endothelial corneal dystrophy• 92015 – 371.57 endothelial corneal dystrophy• 92286 – 371.57 endothelial corneal dystrophy• 76514 – 371.20 corneal edema

• To VSP• 92310 Specialty Maximum for preferred contact lens – 371.57

endothelial corneal dystrophy

Example #2• Dx = endothelial guttata/endothelial corneal dystrophy• Billing option 2:• To medical insurance:

• 92286 – 371.57 endothelial corneal dystrophy• 76514 – 371.20 corneal edema

• To VSP• 92004/14 – 371.57 endothelial corneal dystrophy• 92015 – 371.57 endothelial corneal dystrophy• 92310 Specialty Maximum for preferred contact lens – 371.57

endothelial corneal dystrophy

Example #3• 28WM• Adequate but not great vision in current toric SCL’s; feels it’s as

good as it’ll get• Eyes feel dry, frequent redness, uses AT’s often• Regular, symmetric, oblique astigmatism on topography• MR: • OD -2.00-2.00x040, BCVA 20/20• OS PL-1.00x135, BCVA 20/20

• Dx?• Billing?

Example #3• Dx = dry eye syndrome, anisometropia (in any meridian),

myopia, regular astigmatism• Billing option 1:• To medical insurance:

• 92004/14 – 375.15 Tear Film Insufficiency• 92285 – 375.15 Tear Film Insufficiency• 92015 – 367.31 Anisometropia

• To VSP• 92310 Basic Visually Necessary Maximum for preferred contact lens

– 367.31 Anisometropia

Example #3• Dx = dry eye syndrome, anisometropia (in any meridian),

myopia, regular astigmatism• Billing option 2:• To VSP

• 92004/14 – 367.31 Anisometropia• 92015 – 367.31 Anisometropia• 92310 Basic Visually Necessary Maximum for preferred contact lens

– 367.31 Anisometropia

Example #4• 25AF• Running out of contacts. Vision a little blurry; tends to change

every year. Itchy eyes.• Regular, symmetric, WTR astigmatism on topography• MR:• OD -8.00-2.25x180, BCVA 20/20-• OS -7.00-2.25x180, BCVA 20/20-

• Dx?• Billing?

Example #4• Dx = seasonal allergic conjunctivitis, high ammetropia/myopia

(in any meridian), regular astigmatism• Billing option 1:• To medical insurance:

• 92004/14 – 372.14 Allergic conjunctivitis• 92285 – 372.14 Allergic conjunctivitis• 92015 – 367.1 Myopia

• To VSP• 92310 Basic Visually Necessary Maximum for preferred contact lens

– 367.1 Myopia

Example #4• Dx = seasonal allergic conjunctivitis, high ammetropia/myopia

(in any meridian), regular astigmatism• Billing option 2:• To VSP

• 92004/14 – 367.1 Myopia• 92015 – 367.1 Myopia• 92310 Basic Visually Necessary Maximum for preferred contact lens

– 367.1 Myopia

Example #5• 65WF• Hx of spherical, single vision PCIOL Sx six months ago, OD only.

Happy w/ results. OS mild blur uncorrected, good vision w/ new PALs. Some glare at night. Occasional dry eyes.

• MR:• OD +0.25 DS, BCVA 20/20• OS +1.00 DS, BCVA 20/20

• Dx?• Billing?

Example #5• Dx = dry eye syndrome, pseudophakia, hyperopia, presbyopia• Billing option 1:• To medical insurance:

• 92004/14 – 375.15 Tear Film Insufficiency• 92285 – 375.15 Tear Film Insufficiency• 92015 – V43.1 Pseudophakia

• To VSP• 92310 Specialty Maximum for preferred contact lens – V43.1

Pseudophakia• Consider Necessary Spectacles over Contacts - Presbyopia

Example #5• Dx = dry eye syndrome, pseudophakia, hyperopia, presbyopia• Billing option 2:• To VSP

• 92004/14 – V43.1 or 367.0 or 367.4• 92015 – V43.1 or 367.0 or 367.4• 92310 Specialty Maximum for preferred contact lens – V43.1

Pseudophakia• Consider Necessary Spectacles over Contacts - Presbyopia

The End!• Questions?