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Stephanie L. Woo, O.D., F.A.A.O., F.S.L.S.

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I am not a billing EXPERT like them!

This is a repeat from the lecture from GSLS, items may have changed since that date.

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y Bill a scleral lens fit with materials step-by-step for VSP, EyeMed, Davis

y Bill a scleral cover shell through Medicarey Describe billing and reimbursement differences

between medical insurance and vision insurancey Identify 2 differences between vision insurance and

medical insurance billingy Keep in mind, this is the interpretation that I have

regarding the multiple conversations I have had with different representatives of these insurances

y Billing and coding is a leading source of frustration for practitioners

y Reimbursement rates vary vastly between insurance carriers, and it is often times difficult to get a clear answer on how to bill appropriately

y I think of billing and coding the same way as taxes and accountantsy If you take the same tax documents to different

accountants, they interpret the information differently

y Most vision insurances reimburse well for scleral lens fittings and devices

y Scleral lens fittings usually reimburse more than corneal GP fitting, custom soft lenses, and hybrid lenses

y Scleral lenses usually reimburse more than soft lenses, corneal GP lenses, and hybrid lenses

y In conclusion, scleral lenses can be a profit source within your practice and a good source of revenue

y Medical insurances can be more difficult to obtain appropriate reimbursement

y If you accept many different types of medical insurance, it can become tedious and time consuming figuring out your patient’s benefits

y Some practices bill each visit to the insurance (more on this later)

y Scleral lens fitting fees range from low to high depending on the practitioner and the practice

y Advice: Determine the amount of time needed at each visit to develop a fee schedule

y Consider the amount of time necessary for:y Consultation y Scleral lens fittingy Scleral lens dispensey Scleral lens trainingy Scleral lens follow up(s)

y Consider the cost of supplies during each visit:y Consultation (special equipment, testing, etc) y Scleral lens fitting (plungers, dental bibs, non-preserved

saline, NaFl, etc)y Scleral lens dispense (special equipment and testing)y Scleral lens training (scleral lens kit and supplies)y Scleral lens follow up(s)

y Considering the amount of time the patient is allotted, the amount of DOCTOR time with the patient, and the cost of supplies and special equipment, develop a fee schedule that is aligned with your chair time costs

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y Vision insurances usually incorporate the scleral lens fitting and lenses into one lump sum, which includes the lens fitting, dispense, all follow ups within a certain time period, and lenses

y Medical insurances will pay for the fitting as one charge, the lenses for one charge, and all follow ups are billed as separate charges

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

92072 - FITTING OF CONTACT LENS FOR MANAGEMENT OF KERATOCONUS, INITIAL FITTING

Codesafeplus.com as of 1/20/2015

V2531 - CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)

92313 -

PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEOSCLERAL LENS

92310 includes the fitting for BOTH eyes

92313 includes the fitting for BOTH eyes

92072 is a unilateral code, except with Medicare (bilateral)

Vision InsuranceCode Your fees

Scleral Lens fit OU92313

$200

Scleral lens deviceV2531-RT

$400

Scleral lens deviceV2531-LT

$400

Total billed to vision insurance

$1000 as one lump sum for all services and lenses

Code Your fees

Scleral Lens fit OU 92313 $200

Scleral lens device V2531-RT

$400

Scleral lens device V2531-LT

$400

Scleral lens dispense 99213

$100

Scleral lens follow up 99213

$100

Each visit is billedseparately

Medical Insurancey Most vision insurances will reimburse for medically

necessary contact lenses (each insurance’s criteria and reimbursement rates are different)

y Most all vision insurances will cover either glasses or contact lenses, but not both

y This also holds true for medically necessary contact lenses

y If the patient has used their benefits for glasses or contacts this year, they will not be eligible for medically necessary contact lenses

y If you find a patient who is a candidate for scleral lenses, call VSP to find out if they are eligible for medically necessary contact lenses

y If the patient is eligible, they will give you an authorization number

y After the contact lens fitting, log onto eyefinity.com

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Since 92313 is a bilateral code, you do not have to split it up with RT and LT. I like doing it this way because it is very detailed and VSP billing approves of it. Either way is ok

DO NOT FORGET BOX 19!

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y VSP pays based on the TYPE of contact lens fitting performed and the TYPE of contact lens

y As a general rule, VSP pays higher for scleral lens fittings and scleral lenses compared to other modalities.

y VSP also pays according to the diagnosis – they will pay more for what they determine to be more severe diagnoses

Information as of 1/26/2015

Visually Necessary Contact Lens Specialty MaximumsIf billing with CPT code 92072, 92311 or 92312, 92313 or one of these diagnosis codes:

264.6 370.63 371.16 371.46 371.58 871.0

279.50 370.8 371.20 371.48 371.60 871.1

370.00 371.00 371.23 371.49 371.61 871.5

370.01 371.01 371.30 371.50 371.62 871.6

370.02 371.02 371.31 371.51 371.70 871.9

370.03 371.03 371.40 371.52 371.71 940.2

370.04 371.04 371.41 371.53 371.73 996.51

370.05 371.05 371.42 371.54 379.31 V42.5

370.06 371.11 371.43 371.55 743.35 V43.1

370.07 371.12 371.44 371.56 743.41

370.61 371.13 371.45 371.57 743.42

Information as of 1/26/2015

HCPCS AnnualReplacement1

PlannedReplacement1

DailyReplacement1

V2500* $451 — —

V2501* $585 — —

V2502* $691 — —

V2503* $605 — —

V2510* $657 — —

V2511* $800 — —

V2512* $900 — —

V2513* $825 — —

V2520 $500 $650 —

V2521 $679 $804 —

V2522 $750 $863 —

V2523 $650 $775 $800

V2530* $700 — —

V2531* $2,300 — —

V2599** $1,300 $1,650 —

Piggyback $1,300 $1,650 —

Information as of 1/26/2015

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y If you think a patient may be a good candidate for scleral lenses, have your billing department call Eyemed and ask if the patient is eligible for medically necessary contact lenses.

y If they are eligible, they will give you an authorization number

y Print the medically necessary form (1 page), fill out the form, and fax back to Eyemed.

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Includes contact lens evaluation/fit and follow ups and materials

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y Call Davis to find out if patient is eligible for medically necessary contact lenses

y If patient is eligible, fill out the 1 page letter, send to Davis and an optometrist will review it, and make edits to your fees (maybe) and then confirm the total

y Unique: You have to submit this form AFTER you perform the fitting

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y You can bill contact lens services and materials to medical insurances

y Reimbursement rates vary, depending on the insurance carrier

y Any scleral lenses or scleral lens cover shells that are billed to Medicare will need to be billed to Durable Medical Equipment (DME)

92072 - FITTING OF CONTACT LENS FOR MANAGEMENT OF KERATOCONUS, INITIAL FITTING

92072 (MAXIMUM REIMBURSEMENT) $135.06

Codesafeplus.com as of 1/20/2015

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y You can bill V2531 ( CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS )

y You can bill scleral cover shell V2627 in the event that you are fitting a scleral lens for dry eye

CMS ESTABLISHED CEILING VALUE $622.47

CMS ESTABLISHED FLOOR VALUE $466.85

CMS ESTABLISHED CEILING VALUE $1638.13

CMS ESTABLISHED FLOOR VALUE $1228.60

Codesafeplus.com as of 1/20/2015

Item/Service DescriptionScleral shell (or shield) is a catchall term for different types of hard scleral contact lenses.Indications and Limitations of CoverageA scleral shell fits over the entire exposed surface of the eye as opposed to a corneal contact lens which covers only the central non-white area encompassing the pupil and iris. Where an eye has been rendered sightless and shrunken by inflammatory disease, a scleral shell may, among other things, obviate the need for surgical enucleation and prosthetic implant and act to support the surrounding orbital tissue.In such a case, the device serves essentially as an artificial eye. In this situation, payment may be made for a scleral shell under §1861(s)(8) of the Act.Scleral shells are occasionally used in combination with artificial tears in the treatment of "dry eye" of diverse etiology. Tears ordinarily dry at a rapid rate, and are continually replaced by the lacrimal gland. When the lacrimal gland fails, the half-life of artificial tears may be greatly prolonged by the use of the scleral contact lens as a protective barrier against the drying action of the atmosphere. Thus, the difficult and sometimes hazardous process of frequent installation of artificial tears may be avoided. The lens acts in this instance to substitute, in part, for the functioning of the diseased lacrimal gland and would be covered as a prosthetic device in the rare case when it is used in the treatment of "dry eye."

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=235&ncdver=1&bc=AgAAQAAAAAAAAA%3D%3D&

y Perform any dry eye testing that you have within your clinic to document medical necessityy Dry eye questionnairey Schirmer’s or phenol red thread testy Lissamine green stainingy Fluorescein stainingy Anterior segment picturesy Document tear break up time (TBUT)y Tear osmolarity (if available)

Provider info here

Provider info here

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y Billing scleral lenses to vision insurance and medical insurance does not have to be difficult if you use the right codes

y Insurance reimbursement rates vary drasticallyy Price your scleral lens fees appropriately based on the

amount of time spent with the patient and necessary supplies/equipment

y This lecture will be available as a recorded webinar on sclerallens.org in the near future

y I wish you much success with scleral lenses!

Marketing and growing your scleral lens practiceDr. Jason Jedlicka

Wednesday, November 4th (9pm EST)