Medical insurances usually don’t cover contacts unless they are considered medically necessary–and even then, many don’t cover at all.  Contact lenses are defined as medically necessary when the patient has an eye disease or prescription that has to be managed with contacts  because glasses can’t provide sufficient correction. Examples of diagnoses that may qualify for medically necessary contact lenses are keratoconus, aphakia, post-corneal transplant, corneal dystrophies, ametropia, and anisometropia.

Many commercial medical carriers don’t cover medically necessary contacts.  If they do, you have to be careful about reimbursements on a commercial fee schedule. Sometimes insurance reimbursements are not enough to cover the office’s cost on specialty lenses because the newer technology is so expensive. Therefore, it is critical to call the patient’s insurance and verify benefits prior to ordering or dispensing contacts.  When checking benefit information, always get a dollar amount, not just coverage as a percentage of their allowance.  (For example, 80% can mean 80% of $150 or 80% of $1,200. You have to know!)  Ensure the insurance allowance is enough to cover your costs because you cannot charge your patient any overage.

Also, with commercial carriers you can file a claim for each office visit during the fitting process.   Routine vision carriers treat 92310 as a global fee; however, per CPT coding guidelines 92310 is not actually a global code.  Therefore, each time the patient comes into the office, create a claim with a per-visit fee when filing to commercial carriers.   NOTE:  If the patient’s diagnosis is keratoconus, some commercial companies require that the initial visit be filed with 92072. Follow up visits can then be billed with 92310 or some doctors use a lower level E&M code.

Please note that the rules for filing with routine payers like VSP or EyeMed are different and very clearly defined.  However, if you anticipate filing an insurance claim to a medical carrier, you’ve got to know the patient’s benefit before you start the process.  In order to help, we have attached a predetermination form your practice can use when verify benefit information with commercial carriers.  Just click on the link below!

Med Nec CL Predet for Commercial Ins

3/30/14   The deadline is here for the new CMS 1500 02/12 HCFA forms in preparation for the nation’s move to ICD-10s.  By April 1, practices that file any paper claims must have upgraded their software with the new insurance templates.  The new form will have slots for 12 diagnosis codes rather than four, and codes will be sequentially noted by alphabetic pointers rather than numeric.  Among other changes, patient’s marital and employment/student status (box 8) and balance due (box 30) have been eliminated on the forms since these are not reported on 837P electronic claims.

If you have not done so already, talk to your practice management software vendor about upgrades to your system since payers will no longer accept the old 08/05 forms after April 1.  As of this writing, however, some optometric softwares are having to make last minute adjustments to meet the deadline.  OfficeMate had to pull their 11.1 version the week prior to the deadline, and Revolution EHR had to delay their scheduled upgrade. The MaximEyes’s upgrade has the required new format but as of right now, billers have to physically change number pointers to the corresponding letters.  If you have questions about the new HCFA format, contact your vendor for additional information.

The change to the new HCFA format only affects paper claims, at least until October (either 2014 or 2015, depending if the bill that passed the House this week and is on it’s way to the Senate is ratified).  We contacted four major clearinghouses– TriZetto/Gateway, OptumInsight/ENS, Emdeon, and Apex– and confirmed that even if you haven’t upgraded your software by April 1, your electronic claims will still process.  However, practices that use Print Image files to submit their e-claims rather than ANSI files will have to contact their clearinghouses to have their files remapped after they upgrade their systems.

ICD-10 changes promise to make life interesting for all of us in the industry!  It’s critical that practices regularly check their clearinghouse rejections and stay on top of their AR reports to ensure claims are going through and getting paid.  We expect ICD-10 to be even more problematic than 5010 was two years ago, and doctors would be wise to lay back a cash reserve to help carry them through the transition if we see similar issues that delayed transmission and processing of claims.  Every vendor, clearinghouse, and payer in the country will face the unique challenges that such a massive overhaul as ICD-10 will bring.  However, Optometric Billing Solutions weathered 5010 very well because we had the processes in place to ensure every claim got paid as quickly as possible.  Because they had us as a safety buffer, most of our practices were not even aware of the turmoil that affected their colleagues, and we are already planning to make ICD-10 go as smoothly!

4/2/14 Addenda:  The Senate passed the bill that included the delay of implementation of ICD-10 codes until  October 1, 2015, and last night President Obama signed the bill into law.  Certainly there are pros and cons to this delay, but on the plus side it will give practices additional time to prepare for the transition.  The new 02/12 HCFA forms, however, were not affected by the bill, and your practice is still required to upgrade your software to submit paper claims on the new forms.