Code contact lens-related pathologies as medical conditions

Issue: July 2006

ByMichael D. DePaolis, OD, FAAO

Michael D. DePaolis, OD, FAAO [photo]
Michael D. DePaolis

In the world of medicine, eye care in general – and optometry in particular – is somewhat unique. We are one of the few specialties that provide both medical and “retail” services.

While it’s true that the eye care and corrective devices we offer are medically necessary, the latter is often construed as a retail experience. This perception has been largely fueled by the eye wear “shopping” public, and it has also been perpetuated by insurers. Certainly, the proliferation of supplementary vision care plans – providing only well eye exams and an eye wear benefit – is proof positive.

Medical care vs. vision care

While the concept of separate medical and vision care insurance makes sense on certain levels, it also creates a fair amount of confusion. We’ve all had the unenviable task of explaining to a patient why his or her comprehensive major medical plan makes no provisions for a routine eye exam. Or why it doesn’t cover a pair of therapeutic contact lenses for keratoconus. In each scenario, the patient perceives his or her needs as “medically necessary,” while the insurer sees it in a completely different light. We providers are often caught squarely in the middle.

The convergence of medical and vision care is even more evident when a contact lens wearer presents with infiltrative keratitis. While an adenoviral etiology is plausible, it is more likely related to some aspect of contact lens wear. This begs the question: how should such a visit be handled?

If it occurs during an initial contact lens prescribing “global period” or in a patient covered by an annual contact lens “service agreement,” should it be considered a contact lens visit? Given the presence of a recognizable medical diagnosis – regardless of cause – should it be coded as a medical visit?

Medical conditions resulting from contact lenses

A variety of anterior segment pathologies result from contact lens wear, but they are, nonetheless, medical conditions. It is for precisely these reasons that patients have health care insurance. In treating these scenarios as medical visits, we are merely following a precedent set throughout medicine. Orthopedic surgeons repair skiing-related ACL injuries, allergists manage smoking-related asthma and internists treat obesity-related type 2 diabetes on a daily basis. While these conditions result from lifestyle choices, each is a major medical covered service.

Viewed in this light, the issue seems pretty straightforward. Contact lenses are exceptionally safe and effective; however, complications do occasionally occur. In this situation, our approach should be no different than for any other medical visit: perform the necessary tests, make the correct diagnosis, prescribe the appropriate treatment and code the visit accordingly. Simply put, it’s a solution that benefits the patient, works for the provider and is understood by insurers. In short, it makes sense to everyone … now, that’s really unique.