CODING FOR SPECIALTY FITS
Coding Irregular Cornea Contact Lens Fits
Learn tips for obtaining proper reimbursement for difficult contact lens cases.
By Mark A. Ventocilla, OD, FAAO, & Christine W. Sindt, OD, FAAO
Dr. Ventocilla is a clinical professor with the Michigan College of Optometry and has a private practice in Norton Shores, Mich. He is also editor of the AOA Contact Lens and Cornea Section newsletter.
Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is also an AOA Contact Lens and Cornea Section Council Member.
My (Dr. Ventocilla) first attempt at managing post-surgical irregular astigmatism was an experience in both fitting and billing. I was fresh out of optometry school and had observed very few medical contact lens fits. Like many practitioners, I experienced the thrill of the fit and the agony of poor reimbursement. Looking back, I realize how much I've grown in my medical contact lens practice. Not only am I more knowledgeable in contact lens options, I now see that billing and coding are as important as the treatment plan itself.
We'll review a case of a post-LASIK contact lens fitting and subsequent follow-up visits in which we'll discuss not only the patient's care, but also appropriate billing strategies.
Fitting a Post-LASIK Cornea
The patient, the chief administrator at a local hospital, was experiencing debilitating monocular diplopia and was unable to work. Being somewhat gunshy of more surgery, she presented to the office by referral from her LASIK surgeon.
Upon sitting down at the slit lamp, it was easy to see that surgical debris trapped under her flap (Figure 1) had caused a localized elevation (Figure 2), precipitating her diplopia. One treatment option was to lift the flap and remove the debris, but the patient was adamant that we first exhaust all non-surgical options. We fit a spherical GP contact lens, eliminating the diplopia and restoring her vision to 20/20.
What to Bill We coded the appropriate level consultation code (9924X), a contact lens fit (92310), topography (92025), photography (92285) and the contact lenses (V2510) at this visit. You're billing for two components:
1. The examination of the eye.
2. The fit and prescription of the contact lens.
Bill these two components separately using an evaluation and management (E&M) code for the office visit and a contact lens fitting/evaluation code. Therefore, as long as the patient is wearing the contact lens, you may bill an office visit (plus ancillary testing) and a contact lens evaluation charge at every visit.
We chose a consultation code based on the appropriate level of documented history, examination and decision-making as well as the fact that the patient had been referred to our office. In compliance with documentation requirements for consultation codes, we composed a letter back to the referring physician detailing our efforts. Frequently, consultations for medical contact lens fittings are requested by another physician; in these cases, use consultation codes (99241-99245) instead of office visit codes (99201-99205). You may bill a consultation code every time a consultation is requested by another physician; however, if you assume care, bill future visits as E&M visits. Consultation codes are generally reimbursed higher than E&M codes, as more effort is required with performing the examination. Indeed, a critical feature of a consult is the documentation in your medical record stating that your services were requested. You also need to provide written correspondence to the referring physician on what you actually performed.
Bill most contact lens fits under the 92310 code. Use this code regardless of form of payment (private pay vs. insurance coverage). Charge a 92310 code for one fitting including incidental revisions. Common practice is to bundle a number of visits; however, you can charge this code for every visit in which you determine a new lens design and prescription or in which the current fit is significantly altered. Incidental revisions such as power changes aren't billed as a new fitting.
It's important to understand that you should use the modifier 52 only if fitting one eye. If fitting a patient for aphakia, use code 92311 for one eye, 92312 for both eyes and 92313 for a corneoscleral lens. These codes are associated with numerous reimbursement issues, so it's important to know the reimbursement amount before submitting.
A patient is considered new if you haven't evaluated him for three or more years. If you've never examined a patient before but a doctor within your group has provided services within the last three years, the patient is considered established. Table 1 shows how to determine E&M codes for new and established patients.
Billing for Ancillary Testing You can bill separately for refraction, photography and topography. Practitioners often inappropriately consider these tests to be part of the fitting process rather than separate billable charges. If ancillary testing is necessary as part of the fitting process, explain to the patient that these are additional procedures with additional fees. Asking patients to sign an informed consent will eliminate the surprises of additional fees.
Figure 1. Debris trapped under the flap for a post-LASIK patient.
92025 Topography (also coded as S0820 for some non-Medicare plans) To file topography with an insurance claim, you must provide an image of the topography or a reference-able topography database, as well as an interpretation or report with the medical record. Remember, Medicare recognizes one code and insurance companies often recognize another. It will vary by state whether you can bill topography only for the eye with the pathology or if a standard fee covers both eyes. This is a bilateral code; don't bill each eye separately using modifiers.
Generally, you need to bill topography with specific diagnoses such as irregular astigmatism, keratoconus, corneal scar or corneal transplantation. There are a number of other applicable diagnoses, which vary by state and carrier. It's best to check ahead of time.
92285 Anterior Segment Photography Photography may appear to be an obvious charge when performing a prosthetic color match; however, there are other situations in which photography is appropriate during a contact lens fitting. Photography may be necessary when communicating with the laboratory. Photography can more accurately capture the details of a fluorescein pattern so that it may be related to corresponding topography. It may be necessary to document a pre-existing condition, such as corneal scarring, microcystic edema or neovascularization. Photography is a superior form of documentation to a drawing in a chart.
To bill for photography, you need to print and place the photographs in the patient record, download them to the patient electronic medical record or document them in the patient medical record and keep them in a separate reference-able database. Photography is considered a unilateral procedure, so use the modifier 50 when performed bilaterally.
92286 Special Anterior Segment Photography Use this code when performing endothelial cell counts. Endothelial cell counts are helpful in determining the appropriateness of fitting contact lenses in diseased eyes, such as cases of graft failure or Fuch's dystrophy.
Follow-up Visit One Despite our best efforts to vault the corneal irregularity, the patient returned for follow-up care with improved vision but in pain from a corneal abrasion at the raised site. We discontinued lens wear and prescribed Ciloxan (Alcon) drops q.i.d. for one week. We then refit a piggyback lens system, hoping to better protect the cornea.
What to Bill? For this follow-up visit we coded the appropriate level E&M (99213) for diagnosing and treating the corneal abrasion as well as a contact lens fitting fee (92310). Frequently with medical fits, you observe complications at follow-up visits. These complications often lead to a higher level of billing because of a more comprehensive history and examination, as well as a higher complexity of decision-making.
Follow-up Visit Two Unfortunately, at the next visit the patient complained that discomfort with the piggyback system caused a significant decrease in wearing time. We then refit her into a SoftPerm (CIBA Vision) contact lens, the only hybrid lens available at the time of this patient's fitting. The SoftPerm lens was helpful in this case because it has minimal lateral movement and therefore little friction over the area of elevated cornea. The rigid center resolved her diplopia and the lens remained centered because of the soft skirt.
Figure 2. Localized elevation demonstrated with corneal topography on a post-LASIK patient.
Disadvantages for SoftPerm lenses include reduced oxygen permeability (Dk of 14) and marked susceptibility to breakage at the GP/skirt junction (Figure 3). Chung et al (2001) in a retrospective study of 33 patients fit with SoftPerm lenses at Wills Eye Hospital reported that broken lenses occurred in almost half of the cases they studied (16 out of 33 cases or 48 percent).
The SynergEyes (SynergEyes, Inc.) line of hybrid contact lenses advances the SoftPerm lens concept by incorporating a high-Dk rigid center made from Paragon HDS 100 (Paragon Vision Sciences) material (Dk 100) with a 27-percent water nonionic soft lens skirt. Moreover, the lens is less susceptible to breakage at the GP/skirt juncture and features a skirt radius that can vary independent of the base curve radius.
Figure 3. SoftPerm lens with crack along junction.
Available as the SynergEyes A (standard, Figure 4), KC (keratoconus) and PS (post-surgical), these lenses come in 24-lens diagnostic sets configured with three skirt curve radii for each of eight base curve radii. The SynergEyes KC base curve radii are available in 0.2mm steps while the PS version is available in 0.3mm steps with skirt radii availability of steep, median and flat for every base curve radius. The ability to alter skirt radii independent of the base curve radius allows the lens to better accommodate the full range of corneal diameters and geometry and to avoid edge fluting. Moreover, these lenses feature an aspheric base curve that provides better clarity for eyes that have high degrees of circumferential and radial irregularity.
Hybrid lenses are known to exhibit more movement when fit steeper. Hence, for post-surgical cases, the goal is a base curve steep enough to provide total clearance without bubble formation. Poor or tight fits may result in inflammatory events, so it's reasonable to monitor (and bill) hybrid lens-wearing patients quarterly.
What to Bill? Again, we billed for the medical examination of the patient's cornea (99213) and a contact lens fit. Hybrid lenses are somewhat of an anomaly in that you can bill them as a rigid, soft or other contact lens. The code V2599 (contact lens other) usually requires a description, but often moves the contact lens into a non-covered category, which may allow for better reimbursement.
Future Follow-up Visits Once a patient is comfortable and happy, bill future examinations as 9921X (depending on the level of documentation and diagnosis) with a contact lens evaluation fee (92310). The contact lens evaluation fee can have tiered pricing depending on the type of lens evaluated. For example, you may choose to price soft contact lens evaluations at a lower level than GP lens evaluations, which require greater effort.
Paying the Bills
Think of medical contact lens fittings as medical procedures requiring the prescription of durable medical supplies, not as bundled services. This is especially true given that specialty contact lens fitting may require multiple visits and lenses to achieve an adequate outcome.
When a patient is presenting for a specialty fit, it's important to have the necessary documentation from the referring physician so you can bill for a consultation at the first visit. Contact the insurance company to see if the patient has coverage for services in your office. If you're not a provider for the insurance company or if the patient doesn't have coverage for the services you will provide, call the patient to discuss this issue before the day of the appointment. Discussing insurance benefits on the day of the examination essentially results in a wasted examination slot (should the patient choose to leave), slows you down and may frustrate the patient.
If the insurance company does provide coverage for the patient, send a letter of prior authorization and know what reimbursements will occur before initiating the fit. Bill for the initial and all subsequent visits as you would for treating any other disease. Technicians can bill a level one E&M code without supervision. Therefore, any time a patient presents for technical services, the technician can bill a level one E&M code if the chart documentation is complete.
Also apply the 92325 code when you polish or modify the parameters of a GP lens using a contact lens modification instrument. This is a unilateral service; use modifier 50 when performed bilaterally.
Lens returns and credits can be challenging to manage, so know your manufacturer's warranty. It's vital to know how long the warranty covers a lens, how many exchanges you can make and if shipping and handling are charged on each order.
Warranties differ not only by manufacturer, but also by lens design. Many fitters will reimburse the entire cost of the lens when they make a return. While at first this seems logical, there are hidden costs associated with the lens and restocking fees and/or it's reasonable to expect separate shipping and handling fees.
Keep in mind, you pay your staff to receive and verify the lens, call the patient, dispense the lens and return it if necessary. Some doctors charge a higher up-front lens fee to pay for the laboratory's shipping and handling fee as well as staff time associated with verifying the lens. Others add this as a separate fee for each occurrence. A theoretical advantage to charging a higher fee up-front is that the lens cost is often covered by insurance whereas the shipping and handling fee is an out-of-pocket expense. A potential disadvantage to rolling the shipping and handling fee into the lens charge is that the shipping and handling fee would then be subject to contract adjustments. Many doctors lament that lens reimbursement scarcely, if at all, covers the cost of the lens. Also, your laboratory will not reimburse the shipping fee should a return be necessary. In some cases this could be quite a large amount, completely eliminating any profit margin following repeat exchanges.
Figure 4. The SynergEyes lens.
Fitting irregular corneas requires specialized care and lenses. Billing and coding appropriately for these services is essential if you desire to continue offering this expert level of care. CLS
To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #142.