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September 3, 2015

PROSE® Device – Correct Coding

Joint DME MAC and PDAC Article

Recently the DME MACs have received questions about the proper coding of the PROSE® device (BostonSight). PROSE® devices are designed to rest on the sclera or white part of the eye and are used to treat ocular surfaces diseases, including some types of "dry eye." This article discusses the correct coding of the PROSE® device.

For Medicare billing purposes correct HCPCS coding for this item is determined based upon the condition(s) being treated. When the PROSE® device is used as a treatment for certain types of dry eye (see below) the device must be coded as a scleral shell with HCPCS code V2627 (scleral cover shell).

Coverage criteria for scleral shells (V2627) is outlined in the Centers for Medicare & Medicaid Services National Coverage Determination 80.5 (Internet-only Manual 100-3, Chapter 1, Part 1, §80.5)External PDF. Coverage for V2627 is limited to two conditions:

When the PROSE® device is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531 (contact lens, scleral, gas permeable, per lens) and is subject to the Medicare refractive lens statutory coverage exclusion.

For questions about correct coding, contact the Pricing, Data Analysis and Coding (PDAC) Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC websiteExternal PDF.

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