Coding and Billing for Keratoconus: Medically Necessary Contact Lenses


Note: Applies to US Only.

There are two elements when discussing billing for medically necessary contact lenses. First, what service and material charges are appropriate for this patient, and second, who will pay for these services and materials. It is up to the practitioner to determine what services you provide to your patient, not contracted payers. The payers can only tell you who will pay for those services and at what rate. 

It is of the utmost importance to thoroughly evaluate payer contracts to decide if they make sense for your practice. Several plans reimburse at a rate that will not even cover material costs and also don’t allow for the balance to be billed to the patient. If a payer has a poor reimbursement policy, then you should not contract with that payer.

Coding and Reimbursement

The ­first element in reimbursement is establishing medical necessity. That begins with a chief complaint that is rational to Keratoconus (KC), such as decreased acuity. Thorough, detailed documentation regarding the medical and ocular history, visual acuity, habitual contact lens history, and family history is necessary.

Each diagnostic test must be rational to the chief complaint; it must be ordered, the test must be interpreted, and that interpretation must affect your clinical decision-making. Be mindful that claims for an examination to rule out KC because of a family history of the condition may be rejected. There should be a proximal complaint to the specific patient, such as decreased visual acuity. 

The next element of correct coding is the proper ICD-10-CM diagnosis code. These codes are as follows:

ICD-10-CM Diagnosis Codes

H18.61 Keratoconus, Stable

H18.611 Right Eye

H18.612 Left Eye

H18.613 Bilateral

H18.619 Unspecified Eye

H18.62 Keratoconus, Unstable

H18.621 Right Eye

H18.622 Left Eye

H18.623 Bilateral

H18.629 Unspecified Eye

It is best practice to avoid the “unspecifi­ed eye” codes whenever possible, regardless of the diagnosis code. CPT rules require the provider to use the highest level of specificity that is practicable. Use the H18.61x: Keratoconus, stable codes for disease that is documented as not progressing. Another time to use the stable codes is for the “Emerging/ Mild” category when billing EyeMed. Use the H18.62x: Keratoconus, unstable codes for disease that is documented as progressing, and for the “Moderate/Severe” category when billing EyeMed. (Check the EyeMed “Medically Necessary Contact Lens Benefi­ts” policy.) 

Billing for Services Related to Lens Prescribing and Materials

 The CPT service code for prescribing lenses when the diagnosis is KC is 92072: Fitting of contact lens for management of keratoconus, initial fitting. The plain language of the code rules. The descriptor is “­fitting of contact lens for the management of keratoconus.” This code only covers the diagnostic evaluation visit, or fi­tting, of the medically necessary lenses. It does not cover the ancillary testing or the original eye examination.

Three sub-text instructions apply only to the 92072 code. They are, in order: 1. For subsequent ­fittings, report using evaluation and management services or general ophthalmological services; 2. Do not report 92072 in conjunction with 92071; and 3. Report the supply of lenses separately with 99070 or the appropriate supply code.

The ambiguity of “initial” and “sub-sequent” was cleared up by CPT Assistant, September 2017. “If the lens needs to be changed because it no longer fi­ts the patient’s needs, the ­fitting of a new lens is considered an initial ­fitting.” All other visits required to achieve success are billed according to the sub-text instructions.


Regarding the billing to vision care plans, the best advice is to follow the rules for each plan. At the website, under the “Resources” tab, is a tab for the “Coding and Billing” module. In that module, you can ­find several helpful resources. First, is a two-hour lecture with a hand-out regarding the coding and billing for specialty lenses. 

The two-hour lecture contains a step-by[1]step guide for ­finding and using the policies for the various vision care plans regarding specialty lens prescribing. It encouraged that you to read and print the rules for each vision care plan which you contract. Follow their rules speci­fically, as their rules are uniquely different from each other and from the Principles of CPT.

Using these resources will guide your decision-making process to ensure correct coding and billing for reimbursement. Remember to carefully review payer contracts and select payers that will provide appropriate reimbursement in order to provide patients with the best care.