Bill consistently for contact lens-related conditions

Coding for contact lens complications can present a variety of challenges to practitioners. Many contact lens diagnoses have no specific ICD-9 codes, creating some ambiguity regarding the proper way to bill for such a condition. Another area of uncertainty for many practitioners is whether a service should be covered under the patient’s vision benefit plan or major medical insurance.

Finding effective ways of billing these services is an important skill that will add to the success of any optometric practice.

“When coding for contact lens complications, the practitioner must first understand that it is not only correct to code and bill for the initial visit, but that he or she should code and bill for all subsequent visits until the complication is resolved,” said Carla Mack, OD, FAAO, associate professor at the Ohio State University College of Optometry, in an interview with Primary Care Optometry News. “Second, the practitioner must determine the appropriate Evaluation and Management level (992XX) for the visit based on the level of history, examination and decision-making for the patient’s chief complaint that has been documented in the medical record.”

ICD-9 codes

In situations where a contact lens-related condition has no appropriate ICD-9 code, the practitioner might look for other codes that include some of the findings in the diagnosis.

“The solution is to code the signs and symptoms associated with the condition,” said Peter D. Bergenske, OD, FAAO, an associate professor at Pacific University College of Optometry, in an interview.

Dr. Mack offered guidelines in coding for these signs and symptoms. “If the contact lens-related condition is corneal, consider the use of ICD-9 code 371.82, ‘corneal disorder due to contact lens,’” Dr. Mack said. “Infiltrative keratitis is not found in the numeric listing in the ICD-9 reference guide. However, in the alphabetic section under ‘infiltrate, corneal,’ the code for corneal edema, 371.20, is referenced.”

More specifically, Dr. Mack said, 371.24, “corneal edema due to contact lens,” better describes infiltrates that have formed as a complication of contact lens wear.

Dr. Bergenske discussed a hypothetical case involving a patient who is diagnosed with a superior epithelial arcuate lesion (SEAL). “There is no ICD-9 code for that,” he said. “Instead, the practitioner can legitimately use codes for corneal abrasion, photophobia, epiphora or any other associated finding.”

Vision or medical?

According to Brian Chou, OD, FAAO, of Carmel Mountain Vision Care in San Diego, another confusing aspect of coding is in determining whether a contact lens-related service is covered under the patient’s vision benefit (Vision Service Plan, Medical Eye Service, EyeMed, Davis Vision, etc.) or under major medical insurance (Blue Cross, Pacificare, Cigna, etc.).

“Traditionally, vision benefit plans deal with wellness and prevention, whereas medical insurance deals with sickness and disease,” he told Primary Care Optometry News in an interview. “If a patient is completely new to contact lens wear and develops a contact lens-related infiltrate during the initial period, the question is whether to view the visit as part of the global fees already paid for the contact lens fitting and progress visits.”

The other option, he said, would be for the service to be covered under major medical, in which case the patient would be responsible for some co-payment or deductible. Dr. Chou said this approach may not necessarily be well received by patients.

“Even though practitioners may be justified in going the latter route, doing so could leave patients with a bad taste in their mouths, especially when their expectation is to do well with contact lens wear,” he said. “If a contact lens complication occurs during the initial fitting period, and the patient has an HMO or no medical insurance, practitioners will be even more inclined to write off the medical services they provide.”

However, if a patient has a serious corneal ulcer, Dr. Chou advises practitioners to opt for medical insurance. In this case, “the practitioner is well justified to go the medical route, given the increased requirements for history/examination and decision-making,” he said. “Fortunately, contact lens complications do not occur frequently with today’s healthier lens care systems and contact lens materials.”

Dr. Chou pointed out that improved lens materials do not excuse practitioners from emphasizing good hygiene and recommending daily removal. He added that continuous wear lenses, even in their newest-generation form, could present an added risk for contact lens complications.

“Even with the new silicone hydrogel lenses, the studies are showing that continuous wear is still not as safe as daily removal,” he said. “Consequently, the practices really embracing continuous wear will contend with a higher incidence of contact lens complications. These doctors will need to deal more with the issue of whether to bill patient’s major medical insurance for contact lens-related complications.”

Coding for bandage contact lenses

Another problematic aspect of coding for contact lens conditions is the approach to bandage contact lenses. “There is a lot of confusion here, and it is really very simple,” Dr. Bergenske said. “If a lens is being fit for an acute condition, such as management of pain caused by a corneal abrasion, the code for fitting and dispensing the contact lens is 92070.”

Dr. Bergenske said this is a unilateral code and includes the supply of the lens, which must be a lens that is approved for therapeutic use.

Dr. Chou also uses the CPT code of 92070 for bandage contact lenses. “This is a per-eye code, so the modifier of RT, LT or 50 (both eyes) should accompany the claim,” he said. “Make sure the CPT code is linked with an appropriate diagnosis (e.g., corneal abrasion, 918.1).”

Dr. Mack said when the primary purpose of the contact lens is to promote healing, decrease pain, aid in therapeutic drug delivery and/or help maintain ocular surface hydration, the practitioner should choose the appropriate level Evaluation and Management code, as well as the most specific diagnosis code.

If lenses are being fit for a chronic condition such as keratoconus, Dr. Bergenske said, the proper code for fitting is 92310. “This code is bilateral and does not include the lenses, which should be billed separately using the “V” codes,” he said. “I suggest using the –22 (special circumstance) modifier along with 92310 to distinguish it from routine fitting and to justify the higher fee that typically would be charged.”

PPO panels

Dr. Chou said, in California, the state in which he practices, practitioners who routinely prescribe for keratoconus and corneal transplants should re-evaluate the advisability of becoming a member of a PPO medical panel.

“As an example, my office recently billed one PPO, for which we are providers, for the contact lens prescribing for a keratoconus patient,” he said. “We were reimbursed less than 15% what was billed, which doesn’t even cover the cost of the contact lenses.”

Dr. Chou said because his group is on the panel, they were forced to accept this contracted reimbursement and were not permitted to bill the patient for the balance.

“Unquestionably, this is not financially sustainable,” he said. “So, despite substantial work to get onto the medical panel in the first place, I am now trying to get off the panel. Hopefully, other ODs can learn the lesson that it doesn’t always make financial sense to get on a medical panel.”

Be consistent

Dr. Mack said coding visits, procedures and diagnoses for contact lens-related complications need not be viewed differently than coding for other anterior surface complications.

“Be consistent in coding, no matter the patient or form of payment,” she said. “The medical recommendation must always support the Evaluation and Management level. Choose the most specific diagnosis code or codes that best describe the patient’s condition.”

Dr. Bergenske recommended that practitioners keep some coding information nearby to use as a guideline. “Know the E&M coding system, and keep a ‘guide-sheet’ chair side to make sure you are billing at an appropriate level,” he said.

For more information:

• Carla Mack, OD, FAAO, is associate professor at the Ohio State University College of Optometry. She can be reached at 320 W. 10th Ave., Columbus, OH 43210; (614) 292-0625; fax: (614) 247-6626; e-mail: mack.68@osu.edu.
• Peter D. Bergenske, OD, FAAO, is an associate professor at Pacific University College of Optometry and director of clinical research and development at CIBA Vision. He can be reached at 2043 College Way, Forest Grove, OR 97116; (503) 352-2278; fax: (503) 359-2929; e-mail: berg1101@pacificu.edu.
• Brian Chou, OD, FAAO, practices at Carmel Mountain Vision Care in San Diego. He can be reached at 9320 Carmel Mountain Road, Ste. E, San Diego, CA 92129; (858) 484-1500; fax: (858) 484-9143; e-mail: chou@RefractiveSource.com.