Coding & Reimbursement

Bandage Contact Lens Basics

By Suzanne L. Corcoran, COE

The placement of therapeutic bandage contact lenses, too, have undergone coding changes. I'll review the reimbursement challenges here.

Q. What is a bandage contact lens?

A. A contact lens (CL) usually contains an optical correction for use in lieu of eyeglasses. However, some contact lenses are designed as protective bandages for an eye with corneal disease. Except for aphakic and pseudophakic patients following cataract surgery, CLs prescribed for refractive errors are not separately reimbursed by Medicare and have limited coverage by other third-party payers. However, bandage contact lenses (BCL) used for therapeutic purposes (e.g., to promote healing or for pain management) are covered by Medicare.

Q. When will Medicare cover a BCL?

A. Medicare's National Coverage Determination (NCD) describes covered uses of BCLs: “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 ectasis, 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.

The Indications and Limitations of Coverage listed in the NCD provides special instructions about reimbursement for BCLs. It states: “Payment may be made under §1861(s)(2) of the Act for hydrophilic contact lens approved by the Food and Drug Administration 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 key, 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 personal professional services in the course of diagnosis or treatment of an injury or illness.”

Q. How is a BCL billed?

A. Prior to this year, CPT included 92070 (Fitting of contact lens for treatment of disease, including supply of lens). The code was defined as unilateral, and allowed about $65 per eye. This code has now been deleted from CPT.

Effective January 1, 2012, there is a new code, 92071 (Fitting of contact lens for treatment of ocular surface disease). Medicare defines this code as bilateral; bill once whether one or both eyes are treated. The 2012 national Medicare Physician Fee Schedule allowable is $37.

CPT instructs that the contact lens itself be reported separately as 99070 or an appropriate supply code. However, Medicare identifies 99070 as always bundled with the associated code, so there is no separate payment for the BCL. An appropriate supply code would be V2599 (CL supply not otherwise specified), which is not payable as a physician service.

Q. What other reimbursement challenges should we expect?

A. Medicare will often decline to pay if the frequency of a service is excessive in its 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 your claim. Get the patient's signature on an Advanced Beneficiary Notice of Noncoverage (ABN) prior to 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 the reason why a denial from Medicare is expected, such as “Medicare does not cover more than one replacement lens per month.” A statement that Medicare won't pay is not sufficient.

When a BCL is dispensed during the postoperative period following surgery, Medicare's coverage rules for global surgery apply. MCM §4821 addresses this topic and describes those services included in the global surgery fee, among them: “All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.” Consequently, BCLs dispensed in the office to aid in postoperative recovery are not separately billed or reimbursed.

Sometimes a BCL is applied in the operating room at the end of the case. The facility fee of the ASC or hospital includes this service, so the physician should not charge 92071 as an adjunct to the surgical procedure. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.