Contact Lens Spectrum Supplements

Special Edition 2017

Contact Lens Spectrum

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C O N T A C T L E N S S P E C T R U M S P E C I A L E D I T I O N 2 0 1 7 c l s p e c t r u m . c o m 60 CODING greater than 475 microns. For the "moderate/severe" cat- egory, topography must be steeper than 53.00D, and mini- mum corneal thickness must be less than 475 microns. Of note, Eyemed's maximum reimbursable amount is the same for vaulting hybrid lenses and scleral lenses for severe keratoconus. VSP For VSP, you must file an electronic claim through Eyefinity. After inputting the authorization number, you will see a series of drop-down boxes, one of which will ask for the type of lenses prescribed, which may include: • V2510 for corneal GP • V2521 for toric soft lenses (off the shelf or custom) • V2531 for scleral • V2599 for hybrid You can find a full list of diagnoses that are reimbursed by VSP's MNCL benefit in your provider manual. Absent from the above list is V2627 for scleral shell, the typical code used to designate lenses for patients with severe dry eye when billing medical insurers. The next drop-down box is key for MNCLs. You can se- lect either "Elective Contact Lenses" or "Necessary Con- tact Lenses." After filling in the rest of the requested infor- mation, VSP checks to see if you have satisfied the criteria for MNCLs. If so, the claim is processed electronically. Maximum reimbursement for scleral lenses for 92072 and 92313 with VSP is $2,500. However, in your con- tract with VSP, you agree to give a 10% discount to VSP members, so your maximum reimbursement is actually $2,250. Maximum reimbursement for hybrids with VSP is $1,200. MEDICAL INSURANCE Medical insurers do not bundle fees. All claims follow CPT guidelines. In other words, you code separately for any procedure or test you perform. Common procedure codes used for coding MNCLs for medical insurers include: 99214 — Return comprehensive examination 92072 — Fitting of contact lens for management of keratoconus, initial fitting 92313 — Prescription of optical and physical charac- teristics of and fitting of contact lens; corneoscleral lens 92025 — Corneal topography 92132 — Anterior segment OCT 76514 — Pachymetry 92015 — Refraction V2599 RT, LT — Contact lens, miscellaneous V2627 RT, LT — Scleral cover shell V2531 RT, LT — Contact lens, GP, scleral Coverage of procedures related to MNCLs varies widely among medical insurers. I recommend having pa- tients sign an advance beneficiary notification every year lation, you may want to book extra time and designate extra technician time for MNCL visits. Vision insurers require practitioners to bundle all servic- es for MNCLs into a few codes. This differs substantially from CPT rules and medical insurance guidelines. There- fore, when determining your fees for either 92072 (contact lens fitting for keratoconus) or 92313 (scleral contact lens fitting, used for diagnoses other than keratoconus, such as post-refractive surgery or dry eyes), you must build in the cost of each visit and each test you will be performing. Remember, you signed government and private contracts agreeing not to charge one payer less than another. EYEMED Diagnoses that support filing a claim for MNCLs in- clude: aphakia, high ametropia, anisometropia, keratoco- nus, and vision that can be corrected two lines better with contact lenses than with eyeglasses. (In California, there are a few more provisions.) The plan maximums are listed under each category as follows: Aphakia: $700 High ametropia: $700 Anisometropia: $700 Keratoconus mild/moderate: $1,200 Keratoconus severe: $2,500 Two lines improvement: $2,500 These fees include visits, testing, and lenses. Therefore, it is in the patient's best interest (and mandated by your contract with Eyemed) that if he or she falls within one of those categories, you file the claim as MNCL. High ametropia is defined as refractive error ±10.00D in one meridian at the spectacle plane. Anisometropia is defined as any meridian that differs by more than 3.00D. This is a departure from medical insurers, which do not consider high ametropia or anisometropia to be diagnoses that support medical necessity. There is a provision for mild/moderate keratoconus and a separate one for severe keratoconus. For "emerg- ing/mild" reimbursement, the patient should not have corneal scarring, but should have unstable topography, photophobia, corneal signs such as striae, a steepest cor- neal meridian of less than 53.00D, and corneal thickness T h e r e a r e m u l t i p l e m e t h od s f o r b i l l i n g a n d c od i n g s p e c i a l t y c u s t o m c o n tac t le n s e s .

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