Contact lens fittings can feel like performing precision surgery on the most delicate part of the human body. The same is true when it comes to their billing. Ever wondered why it is so hard to file claims for eyewear fittings and why ophthalmology practices face high denial rates?
Well, the short answer is billing complexity. Ophthalmology is a sensitive medical specialty, and even small changes in similar procedures require completely different billing codes. Contact lens fittings, for example, seem like a simple procedure, yet their billing is quite challenging. The most frequently used code for fitting contact lenses is CPT code 92310.
That’s why we have compiled this guide on CPT code 92310, so you can increase claim accuracy and reduce denials. Whether you’re an ophthalmologist, optometrist, or part of the billing team, this guide is for you. So, let’s start.
What is CPT Code 92310?
The official definition of CPT code 92310 describes it as:
“Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.”
That’s quite a mouthful, so let’s break this down in simpler terms.
CPT 92310 is a comprehensive code that covers the entire process of fitting contact lenses. It’s
used when an eye care professional prescribes and fits contact lenses for both eyes of a patient who still has their natural lenses. However, if the natural lenses are missing (aphakia), 92310 does not apply.
The code covers all components of contact lens prescription and fitting, including the initial assessment, lens selection, fitting process, and follow-up care necessary to ensure proper fit and patient comfort. Also, CPT code 92310 covers billing for a lot of different types of contact lenses, including:
- Standard soft contact lenses (spherical)
- Soft toric lenses for astigmatism correction
- Soft multifocal lenses for presbyopia
- Custom soft contact lenses
- Corneal gas permeable (GP) lenses
- Intralimbal lenses
- Hybrid contact lenses
However, many billers make the mistake of using this code for scleral lenses as well. Please note that it specifically excludes scleral lenses, and they require a different code for billing.
Scenarios Where CPT Code 92310 is Applicable
A simple explanation might not be enough to learn the accurate usage of code 92310. So, let’s look at a couple of real-world scenarios in which it can be used.
Initial Soft Contact Lens Fitting
A 25-year-old patient visits your practice for their first contact lens fitting. After a comprehensive eye examination revealing myopia in both eyes, you perform keratometry, evaluate tear film quality, and fit soft spherical contact lenses. You provide detailed instructions on insertion, removal, and care. This service is appropriately coded as 92310.
Multifocal Contact Lens Fitting
A 48-year-old presbyopic patient seeks contact lens correction for both distant and near vision. You evaluate their pupil size, determine appropriate lens design, and fit multifocal contact lenses with specific add powers. The fitting includes assessment of visual zones and patient adaptation. You can then bill all these services using the single CPT code 92310.
Applicable Modifiers for CPT Code 92310
The following modifiers are commonly appended to CPT code 92310 for enhanced coding specificity and accurate reimbursement collection.
| Modifier | Description | When to Use |
|---|---|---|
| 52 | Reduced Services | When the service provided is less than typically required (e.g., fitting only one eye when the code typically covers both) |
| LT | Left Side | When contact lens fitting is performed only on the left eye. Append after modifier 52. |
| RT | Right Side | When contact lens fitting is performed only on the right eye. Append after modifier 52. |
These are some of the frequently used modifiers with code 92310. However, please note that CPT code 92310 is a bilateral code, which means that it covers the treatment of both eyes. So, in most cases, you will not have to use the RT and LT modifiers in your claim. If for some, the lens is fitted in only one eye, you can use the modifier 52 with the RT/LT modifiers.
CPT Code 92310 – Billing & Reimbursement Guidelines
The following billing tips and tricks will help you reduce the denial rate of your claims with CPT code 92310.
Confirm Insurance Coverage
Medicare typically does not reimburse CPT code 92310 as contact lens fittings are considered routine vision or cosmetic services rather than medically necessary treatments. However, exceptions may apply when contact lenses are prescribed for specific medical conditions such as:
- Aphakia (absence of natural lens)
- High refractive errors where glasses are inadequate
- Anisometropia causing diplopia
- Post-surgical corneal irregularities
However, ophthalmologists or optometrists must confirm the coverage and benefits with the insurance payer before providing any services, even if there is a valid medical necessity. Also, convey to the patient that they might be required to cover the entire cost of the service.
Provide the Necessary Documentation
The following documents and medical records are essential for submitting CPT code 92310 claims:
- Patient’s visual requirements and lifestyle needs
- Detailed ocular measurements (keratometry, pupil size, tear film assessment)
- Lens specifications (power, base curve, diameter, material)
- Fitting rationale and clinical decision-making process
- Patient education provided (insertion, removal, care instructions)
- Follow-up schedule and adaptation monitoring plan
- Any complications or adjustments made during the fitting process
Wrapping Up
CPT code 92310 is a frequently used billing code in ophthalmology. Every year, 4-6 million people opt for contact lenses in the USA. This makes it vital for healthcare providers to get their billing right on the first attempt. Otherwise, they could lose thousands of dollars in revenue leaks. With the help of this guide, healthcare providers can significantly reduce their rate of 92310 claim denials.
However, if you are facing frequent denials or want a helping hand in handling all the complexity of billing, explore our suite of ophthalmology billing services. From accurate coding to denial management, we provide everything.
