COMPLICATIONS AND
CODING
Complications, Care and Coding
See case by case how to diagnose, manage
and code contact lens complications.
By Carla J. Mack, OD, FAAO, and Julie
A. Curtis, OD
There
are many reasons for anterior segment complications including trauma, inflammation,
infection, allergic response, poor contact lens-to-cornea fitting relationship and,
of course, patient noncompliance. Listening to your patients' needs and providing
continuous patient education can help create a relationship that will benefit both
the patient and your practice. Yet, despite our best efforts, complications are
sure to arise, and knowing how to manage and code properly will make your chair
time both efficient and profitable.
Case 1
Because
of our large university-based location, we frequently see corneal complications
secondary to contact lens wear and ocular trauma. A 29-year-old college student
presented with left eye complaints of nasal conjunctival redness, mild eye irritation
and a "white spot" that she'd had on her cornea for two days. She reported no pain,
photophobia or discharge. She had felt a
"bump-like
sensation" and an overall increase in GP lens awareness of the left eye for the
previous two weeks, but continued to wear her contact lenses 16 hours each day.
She discontinued contact lens wear after observing the white spot on her cornea
and subsequently noticed minimal improvement in symptoms.
She reported a
history of corneal ulcers in both eyes and giant papillary conjunctivitis while
wearing monthly replacement soft contact lenses and two-week disposable contact
lenses. She was a college student who majored in dance and instructed yoga. Our
records indicated that she was a successful daily disposable lens wearer, but found
them cost prohibitive. She had successfully worn aspheric GP lenses for several
years. She reported no allergies and her health history was unremarkable.
Slit lamp biomicroscopy
OD revealed faint midperipheral corneal scars at 10 o'clock and four o'clock from
previous corneal ulcers. The left conjunctiva had moderate injection adjacent to
the nasal limbus with overlying fluorescein stain. A corneal infiltrate was present
from eight o'clock to 10 o'clock with elevated, staining, hyperplastic epithelium
and vascularization throughout (Figure 1).
The
right GP lens lid-attached, centered and showed slight central pooling and adequate
edge lift around all 360 degrees. The left GP lens lid-attached, but centered nasally
with the blink, with the nasal lens edge overlying the corneal desiccation. We noted
slight central pooling, midperipheral bearing and minimal nasal lens edge lift with
adequate edge lift elsewhere.
We
diagnosed vascularized limbal keratitis (VLK) OS. Grohe and Lebow first described
VLK in 1989. It's a peripheral corneal disorder induced by GP daily or extended
wear and associated with large overall lens diameters, minimal edge lift designs
and steep base curve-to-cornea fitting relationships. Signs and symptoms include
peripheral corneal desiccation, infiltration and inflammation as well as surface
erosion, discomfort and decreased wearing time.
The
treatment goal is to alleviate the mechanical irritation with ocular lubricants
and GP lens design changes such as decreasing the overall lens diameter, flattening
the base curve and creating a wider, flatter peripheral curve. Other fitting options
include a large-diameter GP lens with increased edge lift or a soft contact lens
that covers the area.
We
advised our patient to discontinue contact lens wear and prescribed a nonpreserved
artificial tear and a steroid suspension. We scheduled a return visit in one week
or sooner should signs/symptoms increase. The etiology appeared both mechanical
and inflammatory.
Evaluation
and Management (E/M) Coding
Accurate E/M coding consists of three key components:
1.
History
2.
Examination
3.
Medical decision making
With
an easy-to-use coding guide sheet, coding for
this patient is easy to determine. Many practitioners would bill this first visit
as a level 2 (99212) established E/M visit and undercharge for their services. A
level 4 (99214) is really more appropriate. My records indicated a detailed history,
expanded problem-focused examination and moderate-complexity decision making. A
99214 established E/M code requires that you have two of the following three items:
1. Detailed history
2.
Detailed examination
3.
Moderate-complexity decision making
It's
important to code other procedures performed when medically necessary as well, such
as external ocular photography (92285), which in this case included interpretation
and report for documentation of medical progress.
Case
1, Visit 2
Our patient cancelled her first appointment and returned two
weeks later, reporting less redness and no irritation OS. The large corneal infiltrate
showed significant improvement, was mildly elevated, had trace staining and was
vascularized throughout. We noted a small intracorneal hemorrhage at this visit
(Figure 2). We instructed the patient to continue the ocular lubricant and to discontinue
the steroid. We advised her to return in one week for a comprehensive examination
and contact lens fitting.
My
records indicated a level 3 E/M code (99213), in which practitioners must document
two of the following three components:
1.
Expanded problem-focused history
2.
Expanded problem-focused examination
3.
Low-complexity decision making
We
also billed external ocular photography, 92285 to show resolution of the VLK and
to document the intracorneal hemorrhage.
Case
1, Visit 3 We successfully fit our patient into a daily wear silicone hydrogel
contact lens because of her concerns of recurrence of VLK, history of corneal ulcers
associated with other soft lens options and financial issues associated with soft
daily disposable lenses. The soft lens covered the affected peripheral cornea, eliminating
any mechanical
sheering forces.
We coded and billed
the following:
•
Comprehensive eye examination (92014)
•
Contact lens fitting (92310)
Case 2
A 20-year-old
college student first presented to our clinic noticing redness and complaining of
a foreign body sensation OD for two days after a weekend getaway in Canada. He had
removed his soft contact lens, cleaned it with an unknown multipurpose solution
and reapplied it. The irritation persisted.
He was unsure what
brand of contact lens he was wearing and replaced them every three to four weeks
with extended wear one night a week. He had no backup spectacles and wore his contact
lenses 15 hours a day. His last full eye examination was three to four years ago,
and he obtained his contact lenses via the Internet.
We
noted circumlimbal injection on both eyes on gross examination. The contact lenses
exhibited minimal to no movement. Slit lamp biomicroscopy revealed a small, superior-central
foreign body on the right cornea as well as several small midperipheral infiltrates
scattered from three o'clock to nine o'clock. An imprint of the contact lens appeared
with fluorescein on both corneas (Figure 3). We noted corneal vascularization in
all 360 degrees, as well as limbal irregularity highlighted by positive and negative
staining on both eyes.
We
removed the corneal foreign body with irrigation and prescribed fluoroquinolone
drops qid to treat the residual abrasion. We advised him that his poor contact lens
fit and poor compliance put him at risk for future inflammation, infection and possible
vision loss. We advised him to get a full eye examination and have his contact lenses
refit.
My
records were consistent with a detailed history, expanded problem-focused examination
and moderate-complexity decision making, indicating a new level 2 E/M code (99202),
in which you must meet all of the following:
1.
Expanded problem-focused history
2.
Expanded problem-focused examination
3.
Straightforward decision making
You
can code this visit in several ways. You could bill the office visit alone, 99202.
You could also
add a –25 modifier to the 99202 and then, as a separate line item, bill for
the corneal foreign body removal without slit lamp (65220). Each procedure code
in this case should have a separate diagnosis code. A third option is to bill for
the corneal foreign body removal alone. Coupling the office visit with a surgical
code often results in denials. For this case, I also billed a 92285.
Case 2, Visit
2
Our patient returned the following day as advised, wearing no lens OD
and wearing the soft contact lens OS. The small corneal abrasion had healed, but
the infiltrates remained OD. Both eyes still demonstrated circumlimbal injection.
We performed a manifest refraction and a gave him a spectacle prescription.
My
records showed a problem-focused history, expanded problem-focused examination and
low-complexity decision making consistent with a 99212. In addition, the refraction,
CPT 92015, was a separate billable procedure that we performed that day.
This
patient returned for one more follow-up visit in which we discontinued all medications
and advised him to not wear his poor-fitting contact lenses and to return for a
comprehensive eye examination. It probably comes as no surprise that he didn't return
for more than a year when he came in with a black eye after being struck on the
left eyelid with a water ski. The patient was still wearing the same type of contact
lenses, replacing them after several months with several days of overnight wear
a week. He had several corneal infiltrates. He even mentioned modifying his own
contact lens powers online to improve his vision.
This
patient had two annual visits to our practice, both for ocular injury and not for
routine eye care or even for symptoms related to poor contact lens compliance. However,
no eyecare practitioner could have ignored the obvious signs of contact lens abuse
and contact lens-related acute red eye. It's extremely important to document such
events, as well as how you educate the patient, in the medical record.
Case #3
A 19-year-old
college student first presented to our practice with complaints of left eye blur,
photophobia and irritation of four-days
duration. He discontinued GP contact lens wear with the onset of symptoms. He hadn't
seen his previous eyecare practitioner in four years. The right GP contact lens
was four years old, and he'd replaced the left GP lens three months prior after
breaking it. The original practitioner hadn't evaluated the contact lens fit or
ocular health in four years and sent the new GP lens without a health assessment.
The patient had worn the contact lenses on an overnight bus trip five days earlier
and experienced some irritation the following day. Slit lamp examination revealed
a 0.5mm superior-central infiltrate with overlying stain on the left cornea (Figure
4). Visual acuity with spectacles was 20/15 OD and 20/50 OS. Pinhole acuity was
20/30 OS. We presumed that the infiltrate was a sterile corneal ulcer because of
the lack of anterior chamber reaction, significant pain or photophobia after four
to five days of onset. We prescribed a fourth-generation fluoroquinolone and instructed
the patient to return the following day.
My
records indicated a detailed history, expanded problem-focused examination and moderate-complexity
decision making, consistent with a 99202. We also billed a 99285.
The
patient returned for two visits over the next seven days. The corneal ulcer healed,
forming a scar, and the visual acuity improved to 20/25+. We advised the patient
about the importance of comprehensive vision care, and he chose to resume care with
his previous eyecare practitioner. We don't know to what extent patient noncompliance
or practitioner negligence played in the development of this GP-induced central
corneal ulcer. The incidence of infectious ulcerative keratitis with GP wear is
rare, but you should never overlook the importance of comprehensive eye examinations
and corneal health evaluations with contact lens wear.
Case 4
A 20-year-old
college student presented with a 30-minute history of mild pain and mild blur of
the left eye. He expressed concern that he had given himself a paper cut on his
eye. Visual acuity OS was 20/25 and the pain was a 4 on a scale of 1 to 10. Slit
lamp biomicroscopy revealed a superficial abrasion
over the left pupil with a jagged diagonal epithelial defect consistent with a paper
cut (Figure 5). We applied a bandage contact lens to reduce the pain and to protect
the corneal epithelial cells from the eyelid. We also prescribed a topical
fluoroquinolone.
We billed a 99202
and a 92285. In addition, we also billed for fitting of a contact lens for the treatment
of a disease (92070). This included the supply of the contact lens.
The
following day the patient's visual acuity had returned to 20/20 and only trace corneal
staining remained (Figure 6).
Completing the Care Circle
Patient
care doesn't end with the assessment and plan. The complete circle of patient care
consists of patient history, patient examination, thought process and decision making,
medical record documentation and coding and billing for your services.
Ongoing care, recall
and regular re-education about proper lens care, hygiene and preventive eye care
may prevent these complications in the future. To make sure you're
compensated for your thinking, medically necessary care and documentation and to
make your chair time worthwhile, code these visits properly.
Click
here for a copy of the code sheet that we use for billing.
To
obtain references, visit http://www.clspectrum.com/references.asp
and click on document #115.
 |
Dr.
Mack is the clinic director and a clinical associate professor at The Ohio State
University College of Optometry. |
 |
Dr. Curtis is a clinical
assistant professor at The Ohio State University College of Optometry. |
Contact Lens Spectrum, Issue: June 2005