How to Bill Keratoconus to Insurance
Many doctors ask me how to properly bill a keratoconus specialty contact lens fitting to insurance.
There are a few differences when it comes to submitting the contact lens fitting to medical insurance vs. vision insurance. However, the most COMMON CPT code that you will use is:
92072 (Fitting of Contact Lens for Management of Keratoconus, Initial Fitting).
Note - this is a BILATERAL code, meaning that you use this code to bill for both eyes. If you are only fitting one eye, make sure to use a modifier.
Whether you are billing vision or medical insurance, 92072 will often be the code you will be using. Please remember that this code only covers the FITTING procedure and nothing else. When you see the patient back for an exam for their dispense, insertion and removal training, follow up care, etc, make sure you are using the proper CPT codes for those visits. Those codes will likely be 99212 or 99213 (or similar), depending on the level of the visit.
I also want to point out that the 92072 code only covers the fitting, NOT the physical contact lens. You must also include the proper V code, depending on the type of lens you fit the keratoconus patient with. If you used a scleral contact lens, the code would be V2531. If you used a rigid corneal gas permeable lens or a hybrid lens or a custom soft lens, you will need to use a different code. Make sure you use the correct V code in case you are ever audited. Some insurance providers also have a different pay scale based on the lens that you use. For instance, VSP will usually pay more for a hybrid contact lens, scleral lens, or piggyback compared to a soft lens or corneal gas permeable lens.
*Make sure to bill for the service and the supply of the lens
Tip: If you are unsure of what code is most appropriate or have questions about how to bill the fit to the insurance company, you can always call the insurance company - many times they are very helpful in answering your questions.
Common questions about keratoconus billing:
Q: Can I bill 92072 more than once?
A: Check with your insurance provider. Most insurance companies (vision and medical) will allow you to use this code once per year. Some insurances allow it more than once per year, and there are others that only allow you to use it once per patient lifetime, but those are rare. Every year that you see your keratoconic patient, you will use that 92072 if you are re-fitting the patient.
Q: If my patient has post-LASIK ectasia or similar, should I use 92072?
A: It depends on the insurance company and your provider manual. There are some insurances that suggest that you use 92072 for patients with post-LASIK ectasia. Other companies recommend that you use a different code.
Q: Is there a difference between mild, moderate, and severe keratoconus?
A: Yes, and that is usually dictated within the provider manual. For example, EyeMed vision insurance has a section that clearly defines what is considered mild vs severe. Make sure you are following these guidelines before billing anything. If you are audited and you billed incorrectly, you could lose thousands of dollars.
*Taken from EyeMed provider manual in 2020. Please keep in mind this information may have changed.
Q: I billed everything correctly, but the insurance reimbursment was much less than I was expecting - what can I do?
A: If you are contracted with a vision or medical plan that allows for keratoconus contact lens fittings, you must abide by their pay schedule. You entered into a contract with them that has specific fees and reimbursement rates.
If you found this helpful, you might find my course on how to bill specialty lenses to VSP valuable!