Maximizing Contact Lens Insurance Benefits: A Guide To Accurate Billing

Billing contact lens insurance correctly can be a confusing process, with different rules and guidelines depending on the insurance company and the patient's plan. It's important to understand the specific coverage and requirements of the insurance plan, as well as any necessary codes for billing. For example, CPT codes are used to bill for the fitting portion, while V codes are used to bill for the supply of the lens. Prior authorization for medically necessary contact lens coverage is often required, and it's crucial to check with the insurance company to understand the expected reimbursement to avoid surprises. Additionally, understanding the difference between routine eye exams and contact lens exams is essential, as vision insurance providers may only cover glasses as medically necessary.

Understand the differences between billing medical insurance and vision insurance

Billing contact lens insurance correctly can be a complex process, and it's important to understand the differences between billing medical insurance and vision insurance. Here are some key points to consider:

Understanding the Differences:

• Medical Insurance: This covers various medical expenses, including doctor visits, tests, treatments, and procedures. It typically involves paying a monthly premium to the insurance company, which promises to help with medical costs in case of injury or diagnosis. It's important to know what your insurance covers, as it may not include routine eye exams or contact lenses.
• Vision Insurance: Vision insurance specifically covers routine eye care and eyewear expenses, such as glasses and contacts. It usually includes routine eye exams, but it may not cover eye surgery or treatment for other medical eye issues. Vision insurance is often used as a supplement to regular health insurance.

Billing Practices:

• Selecting the Right Insurance: When billing, choose between medical and vision insurance based on the patient's chief complaint and diagnosis. If there is a medical sign, symptom, or ongoing care needed for a medical condition, bill medical insurance. For routine eye examinations, bill vision insurance.
• Prior Authorization: Contact the patient's insurance provider (vision and/or medical) to obtain prior authorization for medically necessary contact lens coverage. This step may be required after the patient's initial consultation.
• Understanding Coverage: Know the specifics of the patient's insurance plan. Verify coverage for routine eye exams and medical eye exams. Understand deductibles, co-pays, and reimbursement rates to avoid surprises.
• Billing for Contact Lenses: When billing for contact lenses, use the proper CPT (Current Procedural Terminology) codes for the fitting procedure and V codes for the type of lens. Bill for both the service and the supply of the lens.
• Separate Billing: Never bill both vision and medical insurance simultaneously for the same service. Vision insurance typically covers routine eye exams and related expenses, while medical insurance covers medical diagnoses and treatments.
• Out-of-Network Options: If you are an out-of-network provider, patients may still be eligible for reimbursement from their insurance carrier. They can submit an out-of-network reimbursement form to their insurance company.

Learn the CPT codes for contact lens fittings

CPT codes are used to bill a patient's medically necessary contact lens fitting. CPT stands for Current Procedural Terminology. These codes are published annually by the American Medical Association.

• 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. This code is used when fitting corneal lenses, including standard soft contact lenses, custom soft lenses, soft toric lenses, soft multifocal lenses, corneal GP lenses, intralimbal lenses, and hybrid lenses.
• 92311: Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, with Medical Supervision of Adaptation; Corneal Lens for Aphakia, One Eye. This code is for fitting a corneal lens for unilateral aphakia.
• 92312: Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, with Medical Supervision of Adaptation; Corneal Lens for Aphakia, Both Eyes. This code is used when fitting corneal lenses for bilateral aphakia.
• 92313: Prescription of Optical and Physical Characteristics of and Fitting of Contact Lens, with Medical Supervision of Adaptation; Corneoscleral Lens. This code is for fitting a corneoscleral, mini-scleral, or full scleral lens.
• 92072: Fitting of Contact Lens for Management of Keratoconus, Initial Fitting. This code is used when fitting any lens for a patient with keratoconus. It is important to verify specific keratoconus classification guidelines with the insurance provider.
• 92071: Fitting of Contact Lens for Treatment of Ocular Surface Disease. This code is used for fitting a contact lens to manage ocular surface diseases such as punctate keratitis due to dry eye.

It is important to note that different insurance companies may have specific rules and recommendations for using these CPT codes. It is always a good idea to consult with the insurance company to determine the most appropriate code for a particular case.

Learn the V codes for billing the supply of the lens

When billing for the supply of contact lenses, it is important to use the correct V codes. These codes are used to bill for the contact lens material and are necessary for Medicare and other health insurance providers to process healthcare claims.

• V2510—Contact Lens, GP, Spherical, Per Lens
• V2511—Contact Lens, GP, Toric, Per Lens
• V2512—Contact Lens, GP, Bifocal, Per Lens
• V2513—Contact Lens, GP, Extended Wear, Per Lens
• V2520—Contact Lens, Hydrophilic, Spherical, Per Lens
• V2521—Contact Lens, Hydrophilic, Toric, Per Lens
• V2522—Contact Lens, Hydrophilic, Bifocal, Per Lens
• V2523—Contact Lens, Hydrophilic, Extended Wear, Per Lens
• V2531—Contact Lens, GP, Scleral, Per Lens
• V2599—Contact Lens, Other Type (Hybrid)
• V2627—Scleral Cover Shell
• V2799—Miscellaneous Vision Item or Service

These V codes can have modifiers to indicate the quantity of lenses, as well as whether they are for the right or left eye. For example, V2521 RT quantity 12 would mean that you are billing for 12 hydrophilic soft toric contact lenses for the right eye.

It is important to use the correct V code for the specific type of contact lens being supplied to ensure accurate billing and reimbursement from insurance companies.

Understand the reimbursement methods and rates of your insurance company

Understanding the reimbursement methods and rates of your insurance company is crucial when billing for contact lenses. Each insurance company has its own guidelines, reimbursement rules, and fee structures, and these can vary even between patients with the same insurance plan. Here are some key points to consider:

• Contact the insurance company: Reach out to the insurance company to obtain prior authorization for medically necessary contact lens coverage. This step is crucial, as it will help you understand what is covered and to what extent. You will need the patient's information, diagnosis with proper ICD codes, CPT codes for the type of lens fitting, V codes for the lens type, and information on the patient's deductible, co-pays, and co-insurance rates. Don't forget to ask about the expected reimbursement rate to avoid surprises later on.
• Understand the contract: Review the insurance contract carefully to determine if balance billing is allowed. Balance billing refers to billing the patient for the difference between your usual and customary rates and the insurance company's reimbursement. Most insurance contracts do not allow balance billing.
• Know what's covered: Familiarize yourself with what qualifies as a medically necessary contact lens. Each insurance company has its own rules and guidelines on this. Some companies have a list of patient diagnosis codes that qualify, while others may differentiate diseases into mild, moderate, and severe categories.
• CPT and V codes: CPT codes are used to bill for the fitting portion, while V codes are used to bill for the supply of the lens. Make sure you use the correct codes, as some insurance companies only allow a specific set of CPT codes.
• Reimbursement rates: Ask the insurance company representative about the expected reimbursement rate. Often, they will refer to the manual or contract signed when the insurance was obtained. Don't make assumptions about full coverage; instead, get clear information on reimbursement amounts.
• Documentation: Obtain the representative's name or employee ID, the date and time of the call, and a reference number. If possible, get the information in writing, such as through a fax or online authorization. This documentation will be invaluable if any discrepancies arise later.
• Advanced Beneficiary Notice (ABN): It is advisable to have patients sign an ABN before providing any services. This notice explains that patients are financially responsible for payment if the insurance company does not cover the services rendered.
• Written contract: Provide a written contract that outlines all pricing, office visits, lens upgrade fees, lens warranties, and other relevant details. This ensures that patients understand the entire process and are aware of all costs involved.

Know how to apply for out-of-network reimbursement

If you have an out-of-network contact lens benefit in your vision plan, you can purchase your contact lenses from an out-of-network provider and then submit your order invoice and the appropriate claim form to your insurance company for reimbursement.

• Place your online order: Some online retailers allow you to apply your out-of-network benefits at checkout. You can also purchase your contact lenses from an out-of-network provider and then apply for reimbursement.
• Download the reimbursement form: You can usually find this on your insurance company's website.
• Download the receipt: This is usually available in your account history or sent to you via email.
• Mail, email, or fax the reimbursement form and receipt to your insurance company.

It is important to note that reimbursement methods and rates vary drastically between carriers and even sometimes between patients. It is recommended that you check with your insurance company if you have any questions relating to your insurance coverage or benefit eligibility prior to making your purchase.

Frequently asked questions