Because specialty contact lenses are “medically necessary”—needed due to a disease process or a specific medical condition—you must be very familiar with the requirements for the appropriate use of the codes for your office visits (920XX and 992XX) and for your contact lens services. The Current Procedural Terminology (CPT) definition of contact lens fitting includes these important points:¹

• “The prescription of contact lens includes specification of optical and physical characteristics (such as power, size, curvature, flexibility, gas-permeability). It is not a part of the general ophthalmological services.”

• “The fitting of contact lens includes instruction and training of the wearer and incidental revision of the lens during the training period. Supply of materials may be reported as part of the service of fitting, or may be reported separately using the appropriate supply codes.”

 • “Follow-up of successfully fitted extended wear lenses is reported as part of a general ophthalmological service (92012).”

A handful of CPT codes cover the fitting of contacts:

• Contact lens fitting (92310) is defined by CPT as the “[p]rescription of optical and physical characteristics of and fitting of a contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.”1

A 92310 encompasses fitting services up to the point at which you would issue a contact lens prescription. This code does not include contact lens follow-up care after the lenses have been dispensed.

This code is charged every visit a new lens is placed on a patient’s eye or the fit is altered. Incidental revisions without altering the fit, such as power changes, are not billed as a new fitting. If fitting only one eye, use modifier -52, not the -RT or -LT modifier; this change was implemented in 2011.

• Other therapeutic specialty lens fitting codes include 92071 for ocular surface disease and 92072 for keratoconus. Be familiar with the CPT definitions and documentation requirements of each.

Refining/Modifying Your Fit
In most cases, “incidental revision of the lens during the training period” and “medical supervision of adaptation” are accomplished at the first post-dispensing visit. Once you’re at the point where you’ve ordered the final lenses and provided the patient with their lens prescription, the patient is considered fitted for contacts.

Now, if complications arise, the most appropriate way to bill for an office visit is using the established patient ophthalmologic (9201X) or evaluation and management (9921X) codes. Keep in mind that with many, if not most, specialty contact lens fits, you’re following a corneal or ocular surface disease and not the contact lens—this is particularly evident with keratoconus, in which you’re not following the contact lens itself but instead the keratoconic cornea, in which a contact lens is the treatment.

Many optometrists are giving away thousands of dollars per year by including this “free care.” If you refit a patient, and it is not just an “incidental revision of the contact lens,” then it’s OK to bill another fee for 92310, 92311, 92312 or 92313, along with the appropriate materials V-code or Healthcare Common Procedure Coding System (HCPCS) code for lens supply.
Additional ophthalmic procedures—such as topography (92025) or photography (92285, 92296)—are often necessary in a specialty lens practice, as long as you meet the rules for medical necessity.

Insurance benefits for specialty contact lenses vary greatly, so consult your local carriers’ policies and your provider agreement for specifics on specialty lens coverage.

Keep in mind that the patient must purchase coverage for medically necessary contact lenses—you can’t create coverage if it simply doesn’t exist. So, if there is an exclusion for all contact lenses or no coverage at all, tell the patient at the initial visit what the total charges will be and exactly what the fee does and doesn’t cover, including lens exchanges and office visits. Document this disclosure using an advance beneficiary notice of noncoverage (ABN).

1. CPT 2014 Professional Edition. Chicago, IL: American Medical Association. 2014: 539.