Frequently asked questions about this category of contact lenses

Contact lenses (CLs) are usually considered refractive, to correct vision. But another category of CLs are therapeutic. They are used as a bandage and to promote healing, such as in cases of ocular surface disease; good vision is not a significant consideration.

Below, I address the issues our clients typically inquire about for this category of CLs.

Q. Is fitting a therapeutic CL covered by Medicare and other third-party payers?

A. Yes, when medically necessary. A therapeutic CL and the associated fitting are covered under Medicare’s National Coverage Determinations Manual §80.1, which states, “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, … neurotrophic keratoconjunctivitis and for other therapeutic reasons”. Other third-party payers use similar coverage policies.

Q. How are the charges for a therapeutic fitting and the associated CL identified on a claim?

A. The professional service of fitting is identified by CPT 92071, Fitting of contact lens for treatment of ocular surface disease. Note that the term “lens” in the descriptor is singular, denoting a unilateral service. Separate payment is made for the fellow eye in the event a patient requires two therapeutic CLs.

CPT instructs that the supply of the therapeutic CL is identified as 99070 (miscellaneous supply) or the appropriate supply code (V25xx). Medicare has not issued instructions about how to submit a claim for the CL supply, but the Medicare Physician Fee Schedule payment indicator shows 99070 as not separately reimbursable. Note that your local Medicare contractor will not accept V25xx; these codes are billed to the durable medical equipment Medicare administrative contractors (DME MAC), and the DME MAC only accepts claims for post-cataract eyeglasses or CLs, so a DME claim for ocular surface disease would not be covered.

Q. What is Medicare’s allowed amount for 92071?

A. CPT 92071 is defined as a “unilateral” service, so reimbursement is per eye. In 2021, the national Medicare Physician Fee Schedule allowable for 92071 is $37.34 in-office and $32.80 in a facility. This amount is adjusted by local wages indices in each area. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Q. May a therapeutic CL be fitted by a technician when the physician is not present?

A. Medicare says no. The Indications and Limitations of Coverage listed in the NCD §80.1 states, “Payment may be made under §1861(s)(2) of the Act for hydrophilic contact lens approved by the Food and Drug Administration (FDA) 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 Medicare Benefit Policy Manual, Chapter 15, §60.1, explains, “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.” These services require direct supervision, that is, the presence of the physician in the office.

Other payers may have similar limitations. State laws may also govern what services may be provided when the physician is not present.

Q. May any contact lens be used as a therapeutic CL?

A. Not for Medicare. Only lenses that have received FDA approval as therapeutic bandage contact lenses are eligible for reimbursement when billing 92071. Although this list is not exhaustive, examples of approved lenses include:

• Acuvue Oasys with Hydraclear Plus (Johnson & Johnson Vision)
• Air Optix Day and Night (Alcon)
• Plano T (Bausch + Lomb)
• PureVision (Bausch + Lomb)

Q. Is payment made for therapeutic CLs dispensed in the postoperative period of surgery?

A. Sometimes. If the need for the therapeutic CL is unrelated to surgery, payment may be made. However, when the need for the therapeutic CL is related to surgery, fitting is usually part of the postoperative care and reimbursement is included in the global surgical fee; the supply of the CL is separate and not part of the global package.

Q. Does Medicare limit how frequently this charge may be made?

A. As with all services, payment is allowed only for services that are medically necessary. To support the repeated use of therapeutic CLs, the medical record should clearly note indications. Ocular surface pathology should be noted, as well as comments regarding changes in the patient’s condition.

Medicare may decline payment if frequency is “extraordinary” — a vague period, but keep in mind that a bandage CL is usually used short term as the cornea heals. If you are uncertain about reimbursement for repeat therapeutic CLs, consider using an Advance Beneficiary Notice of Noncoverage and asking the patient to assume responsibility. OM

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