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Article Date: 8/1/2006

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How to Expand Your Billing Options for Silicone Hydrogel Contact Lens Services

These tips will help you choose the right CPT and ICD-9 codes to bill for corneal conditions.
By Carla J. Mack, O.D., F.A.A.O.

Figure 1: Dilated nasal conjunctival vessels of the right eye (HEMA lens) as compared to nasal conjunctival vessels of the left eye (silicone hydrogel lens).

Silicone hydrogel contact lenses have been a welcome addition to our practices, enabling us to provide healthier lens options to manage our patients' visual and medical needs.

Along with the health and therapeutic benefits, another less obvious benefit has emerged: the opportunity to expand our billing and coding options for silicone hydrogel lens wearers.

In this article, I'll discuss how you can fine-tune your billing and coding skills and give you examples of appropriate codes for a variety of patient cases.

Case 1: corneal neovascularization in a teen

One of my established patients, a 16-year-old girl presented with mild complaints about her distance vision. She was a compliant daily disposable soft contact lens wearer for 4 years. Previous comprehensive annual eye examinations were unremarkable. 

Figure 2: Corneal vascularization of the right inferior cornea (HEMA lens) as compared to corneal vascularization of the left inferior cornea (silicone hydrogel lens).

She reported good visual acuity and comfort with her current soft lenses. I noted her average daily wearing time was now 18 hours, an increase of nearly 8 hours from the previous year. A slit lamp examination revealed 360° of 0.5 mm to 0.75 mm of corneal neovascularization in both eyes that had not been documented at earlier visits. She had moderate myopia of –5.00D.

After a discussion with the patient and her father, I refitted her with silicone hydrogel contact lenses for daily wear.

The patient returned 1 week later wearing her previous hydrogel lens on her right eye, because she lost the silicone hydrogel lens. She was, however, wearing the silicone hydrogel lens on her left eye. The differing appearance of the circumlimbal conjunctival vessels and corneal neovascularization between the two eyes was substantial (Figures 1, 2).

Coding for case 1

In this case, the patient had both medical and vision insurance plans. We billed the first visit to the vision insurance provider after collecting the appropriate copay and documented it using the following procedure and diagnosis codes:

6 Coding Tips For Corneal Conditions

1. Be consistent in your coding practices no matter the form of payment.
2. Do not code procedures and diagnoses for contact lens-related complications differently than other anterior surface conditions.
3. Code and bill for the initial visit and all subsequent visits until the complication is resolved.
4. Make sure the medical record documentation supports the Evaluation and Management (E&M) level. The practitioner is responsible for determining the appropriate E&M level (992XX) for the visit based on the history, examination and decision-making for the patient's chief complaint.
5. Use modifiers as indicated. You'll find a comprehensive listing in the American Medical Association's CPT 2006 book.
6. Consider the patient "new" if he or she has not seen you or another doctor in your practice within the last 3 years.

CPTs

92014 — comprehensive, established patient, one or more visits
92015 — determination of refractive state
92310 — prescription and fitting of contact lenses with medical supervision of adaption.

ICD-9s

367.1 — myopia, primary diagnosis
370.60 — corneal neovascularization, secondary diagnosis.

We billed the medical insurance company for the corneal photography performed at the second visit, which documented the changed and asymmetric corneal neovascularization. We used the following codes:

CPT

92285 – external ocular photography

ICD-9-CM

370.60 – corneal neovascularization
Both the comprehensive eye examination and the contact lens fitting may occur over more than one visit.

Case 2: corneal abrasion

Table 1 – New Patient E&M

Level

History

Examination

Decision-making

99201

 

All 3 Components Required

 

 

Problem-focused

Problem-focused

Straightforward

99202

Expanded problem focused

Expanded problem-focused

Straightforward

99203

Detailed

Detailed

Low complexity

99204

Comprehensive

Comprehensive

Moderate complexity

99205

Comprehensive

Comprehensive

High complexity

A 20-year-old college student arrived for an early morning urgent care appointment complaining of severe pain in her right eye after removing her soft toric contact lens in the middle of the night.

She wore her lenses on a 2-month, continuous wear basis but was unsure of her lens brand or prescribed wearing schedule.

A comprehensive review of systems revealed an otherwise healthy patient. She didn't have allergies or take any over-the-counter or prescription medications.

She did have decreased visual acuity in the right eye secondary to an 8-mm corneal abrasion, which probably resulted from the removal of her contact lens. She had no corneal infiltrates or anterior chamber inflammation at this visit.

I diagnosed the patient with a corneal abrasion, prescribed a topical antibiotic ophthalmic solution with frequent dosing and fit her with a silicone hydrogel bandage contact lens that was FDA approved for therapeutic use.

Then I asked her to return the following day for evaluation. She noticed immediate pain relief with the bandage lens in place.

Table 2 – Established Patient E&M

Level

History

Examination

Decision-making

99211

 

Requires physician supervision only

 

99212

 

2 of the 3 Components Required

 

 

Problem-focused

Problem-focused

Straightforward

99213

Expanded problem-focused

Expanded problem-focused

Low complexity

99214

Detailed

Detailed

Moderate complexity

99215

Comprehensive

Comprehensive

High complexity

Coding for case 2: 1st visit

This patient was new to our office, but our medical record documentation supported the following levels of the three components for the patient's chief complaint:

1. Comprehensive history
2. Expanded problem-focused examination
3. Moderate-complexity decision-making

For a new patient, you must have all three components of the three key elements to code at these particular levels. In this case, the expanded problem-focused examination determines the level is 99202 (Table 1).

CPTs

99202 — new level 2
92070-RT — therapeutic contact lens fitting

ICD-9

Figure 3: corneal abrasion, day 2.

Figure 4: corneal abrasion, day 4.
Figure 5: corneal abrasion, day 7

918.1 — corneal abrasion
When the primary purpose of a contact lens is to promote healing, decrease pain, aid in therapeutic drug delivery or help maintain ocular surface hydration, choose the appropriate E&M code and the most specific diagnosis code.

The contact lens fitting should be reported as 92070 with the suitable –RT or –LT modifier. The contact lens dispensed to the patient needs no further designation (V code), since 92070 by definition includes the supply of the lens.

Coding for case 2: 2nd visit

The patient returned the following day with improved symptoms. To fully assess the cornea, I removed the bandage lens and instilled fluorescein (Figure 3). The abrasion had improved to 6 mm. I applied a new therapeutic silicone hydrogel lens and used the following criteria to code for the second visit in which two of the three components were required for a level (Table 2):

1. Problem-focused history
2. Expanded problem-focused examination
3. Low-complexity decision-making.

CPTs

99213 — established level 3
92285-52 — external ocular photography (The -52 modifier indicates a reduced level of service was performed because it was done monocularly as medically necessary.)92070-RT — therapeutic contact lens fitting 

ICD-9

918.1 – corneal abrasion
This patient returned for several more visits until the abrasion was healed. At each visit, we used similar coding methods (Figures 4, 5).

Plugs and piggybacking

I have successfully fit several of my dry eye patients with silicone hydrogel lenses to alleviate their symptoms.
I measure success in these cases by how much symptoms and redness decrease and contact lens wearing times increase.

When punctal plugs are indicated, I use the surgical code 68761 (Closure of Lacrimal Punctum by Plug) for both collagen and silicone punctal plugs. Because this is a surgical code, denials are frequent when it's coupled with an E&M visit and performed on the same day as the initial evaluation. In these cases, I use modifier -25.

Choosing ICD-9 Codes Accurately

Select the most specific diagnosis code or codes that best describe the patient's condition. Consider using ICD-9 code 371.82 corneal disorder due to contact lens (excludes: corneal edema due to contact lens) when applicable.

Keep in mind the primary diagnosis is always representative of the patient's chief complaint or chief presenting symptom.

Code the patient's presenting symptoms when the examination outcome is uncertain or documented as "probable," "suspected," "questionable" or "rule-out."

Report coexisting conditions when they both require or affect treatment. For instance, a patient presenting with a peripheral corneal ulcer and secondary anterior chamber inflammation will have primary and secondary diagnosis codes of marginal corneal ulcer, 370.01 and secondary anterior uveitis, 364.04.

Do not code both a confirmed diagnosis and corresponding signs or symptoms unless the signs or symptoms are not completely explained by the diagnosis. For example, it is not necessary to use both corneal abrasion 918.2 and corneal pain 379.91 if the corneal pain is caused by the abrasion.

Refer to the alphabetical listing in the ICD-9-CM book before referring to the numeric or tabular section when verifying a patient's condition or symptom. For example, you can find corneal infiltrate in the alphabetical listing under infiltrate, corneal 371.20, but it is not specifically referenced in the tabular section.

CPT 68761 must be followed by these appropriate eyelid modifier(s):

   E1 — upper left eyelid
   E2 — lower left eyelid
   E3 — upper right eyelid
   E4 — lower right eyelid

This surgical code designates a 10-day postoperative period. If you must assess an unrelated ocular complaint within 10 days post-op, a -24 modifier must accompany the E&M level.

When using a piggyback system, such as pairing a silicone hydrogel lens with a gas permeable lens for a keratoconus patient, consider using CPT 92310 (contact lens fitting and prescription) with an appropriate fee. Use this code in addition to the proper two- or four-material
V codes (V2510 and V2520), depending on a unilateral or bilateral fitting.

Consider using modifier -22 (unusual procedural service) to help clarify a unique case. You can also code the appropriate ophthalmological service (920XX) or E&M level in addition to the contact lens fitting.

Our responsibility

Silicone hydrogel contact lenses have enhanced our practices by allowing us to provide healthier lens options for patients. What's more, we can use them as problem-solvers and therapeutic solutions in certain cases. However, it's imperative that our role as eyecare providers not end with treatment. We also have a legal responsibility to ensure accurate coding and billing that can be justified with appropriate medical record documentation.

 

Dr. Mack is director of clinics, and associate professor of clinical optometry at The Ohio State University College of Optometry, Columbus, Ohio.

 

 

Current Medicare Allowable For Participating Providers:

99201 = $ 33.88
99202 = $ 60.27
99203 = $ 89.80
99204 = $127.22
99205 = $161.97
99211 = $ 19.67
99212 = $ 35.57
99213 = $ 48.59
99214 = $ 76.33
99215 = $111.41



Optometric Management, Issue: August 2006

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