CPT Code 92311

CPT code 92311 is used for billing a contact lens fitting by healthcare providers.

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What is CPT Code 92311

CPT code 92311 is designated for the fitting of a contact lens for the management of keratoconus, initial fitting. This code is used by healthcare providers to bill for the professional service of fitting a contact lens specifically tailored for a patient with keratoconus, which is a condition where the cornea, the clear front surface of the eye, bulges outward. The initial fitting refers to the first time this service is provided for the patient, involving detailed measurement and evaluation to ensure proper fit and visual correction.

Does CPT 92311 Need a Modifier?

For the CPT code 92311, which is used for contact lens fitting, several modifiers may be applicable depending on the specific circumstances of the service provided. Here’s an ordered list of potential modifiers and the reasons for their use:

1. -25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: This modifier is used if the provider performs a significant, separate evaluation and management service on the same day as the contact lens fitting.

2. -LT and -RT - Left Side and Right Side: These modifiers are used to specify services that are performed on the left eye (LT) or the right eye (RT) respectively, which is crucial in treatments involving the eyes to indicate which eye received the fitting.

3. -EY - Eyeglasses Involved: This modifier is used when the service involves the prescription or adjustment of eyeglasses in addition to the contact lens fitting.

4. -TC - Technical Component: This modifier is used when only the technical component of the service (i.e., the actual fitting of the contact lens by a technician) is provided without the professional interpretation and report by the physician.

5. -26 - Professional Component: Used when the claim is for the professional component (interpretation of results, oversight of the fitting process) of the service only, and the technical component is billed separately.

6. -59 - Distinct Procedural Service: This modifier is used to indicate that the service is distinct or independent from other services performed on the same day. This might be applicable if multiple procedures or fittings are done on the same day but are unrelated.

7. -76 - Repeat Procedure by Same Physician: This modifier may be used if the contact lens fitting needs to be repeated on the same day due to specific reasons like incorrect fitting initially.

8. -GA - Waiver of Liability Statement Issued as Required by Payer Policy: This modifier is used when a waiver of liability statement has been issued because the service is expected to be denied as not reasonable and necessary under Medicare Part B.

Each of these modifiers serves to provide additional details about the service provided, ensuring accurate billing and reimbursement. It’s important for healthcare providers to use the correct modifiers to avoid claim denials and to facilitate timely payment.

CPT Code 92311 Medicare Reimbursement

CPT code 92311, which pertains to contact lens fitting, is generally not covered by Medicare. Medicare typically does not reimburse for vision services, including contact lens fittings, unless they are part of treatment for diseases or injuries that affect the eye. Therefore, routine contact lens fittings would not be eligible for reimbursement under standard Medicare plans.

For specific reimbursement amounts or exceptions, it is advisable to check directly with Medicare or consult the latest Medicare guidelines, as coverage can vary based on the specifics of the patient's condition and the type of Medicare plan they have. Additionally, providers might consider verifying coverage through Medicare Advantage plans, which sometimes offer expanded benefits, including some vision services.

Are You Being Underpaid for 92311 CPT Code?

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately detecting underpayments. With the capability to scrutinize your contracts and identify discrepancies down to specific CPT codes, such as 92311 for contact lens fitting, RevFind ensures that each claim is fully compensated according to your payer agreements. Schedule a demo today to see how RevFind can help secure the payments you are entitled to for every service rendered.

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