This document provides information on medically necessary contact lenses including definitions, benefits, insurance plans, eligibility criteria, billing codes, and examples of how to determine diagnoses and appropriate billing for patients. It discusses criteria for medical necessity including conditions like keratoconus, irregular astigmatism, corneal disorders and transplants, and high ammetropia. Examples are provided of patients' exams and determining appropriate diagnoses and billing codes to use for medical insurance and vision plans. Reimbursement rates for different contact lens types and replacement schedules are also included.

1. Medically/Visually
Necessary Contact
Lenses
Aaron Wolf, O.D.
November 14, 2012

2. 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!)

3. 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?

4. 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.

5. 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.**

6. 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

7. HCPCS Annual Replacement Planned Replacement Daily Replacement
(1-2 lenses) (3-360 lenses) (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 -

8. Visually Necessary Specialty
Criteria
• Keratoconus • Corneal disorder due to contact
• Irregular astigmatism lens (Duh!!)
• Corneal transplant • Congenital anomalies of corneal
• Corneal opacities size and shape
• Aphakia • Alkaline chemical burn of cornea
and conjunctival sac
• Corneal ulcers
• Mechanical complication due to
• Localized corneal corneal graft
neovascularization
• Pseudophakia
• Deep corneal neovascularization
• Corneal pigmentations and
deposits
• Corneal edema unspecified
• Bullous keratopathy
• Folds in Bowman’s membrane

9. 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

10. HCPCS Annual Replacement Planned Replacement Daily Replacement
(1-2 lenses) (3-360 lenses) (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 -

11. Profit Margins Breakdown
(Coming Soon!)

12. Topography
• (Examples here)

13. 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!!

14. 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

15. 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?

16. 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

17. 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

18. 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

19. 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?

20. 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

21. 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

22. 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?

23. 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

24. 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

25. 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?

26. 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

27. 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

28. 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?

29. 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

30. 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

31. The End!
• Questions?