A structured approach
By Deepak Gupta, O.D., Stamford, Conn.
Optometrists are often the first to see keratoconic patients, and we're the best qualified to serve their primary eyecare needs. We can fit them with glasses or contact lenses, or refer them for surgery.
Although many of us are fully capable of managing this condition, a lot of us are frustrated by the resistance of insurance companies to reimbursing us for our services. This article highlights a structured approach to managing and billing for keratoconus, which will benefit both you and your patients.
Corneal topography on this patient
revealed the inferior steepening, which helped to
confirm the diagnosis of keratoconus.
The following is my plan of action for keratoconic patients.
Routine initial full exam for established patients (use code 92014) and new patients (use code 92004). Perform a full comprehensive eye exam. Document such things as corneal thinning, corneal striae, distorted mires, irregular astigmatism, scissors motion on retinoscopy as well as patient complaints about decreased vision, monocular diplopia and photophobia.
If you suspect keratoconus, bring your patient back for an evaluation. I tend not to perform corneal topography along with a full exam because by the time I confirm my suspicion of keratoconus, I've already performed applanation tonometry, which might distort the cornea.
Also, if the patient is a contact lens wearer and you postpone topography, have him discontinue lens wear to minimize corneal distortion. Plus, some insurances won't cover topography if it's performed at the time of the comprehensive exam.
- Intermediate exam (use code 92012) and corneal topography (use code 92499). Conduct an indepth history. Look for any family history of keratoconus or any of the associated factors, such as connective tissue disorders, Down's or Turner syndrome or any atopic conditions. Repeat keratometry, slit lamp examination and
Corneal topography on this patient
also revealed inferior steepening, aiding in the confirmation
of the diagnosis of keratoconus. This is a more severe
case of steepening, but the Rose Ke lens had this patient
Now perform corneal topography. Even if you did so at the initial full exam, repeat here to verify results, especially if the patient is a contact lens wearer. Have him remove his lenses before this visit for as long as possible. If he needs them to see, schedule this appointment on a Monday, so he can wear his glasses on the weekend before the appointment.
If, by the end of this exam, you've confirmed your initial diagnosis of keratoconus, discuss options such as glasses, contact lenses and even corneal transplants with the patient. Typically, you'll proceed with a lens fitting after this visit.
At this point, send the patient's medical insurance company a letter of medical necessity for the contact lens fitting. Include enough detail to support your diagnosis and your reasoning for a contact lens fit. The letter shown on page 82 works well for me. I also enclose a copy of the topography.
During this intermediate visit, have the patient fill out a non-covered release form stating that he's responsible for the bill if the insurance doesn't cover it. If the patient is unsure of his medical coverage, have your office insurance person or the patient get pre-authorization before proceeding with the contact lens fit.
- Keratoconus contact lens fitting (see codes in
letter). Include all contact lens checks in your contact lens fitting fee. Depending on the severity of the condition, estimate anywhere from three to five visits to fine-tune his prescription.
Your contact lens materials fee should cover the most expensive lenses you fit -- generally the specialty RGP lenses. Even if you choose to fit a less expensive lens, it's wise to have one standard price for keratoconus lenses. Plus, you'll probably be billing an insurance company and will want uniform pricing.
It's often best to start with a high Dk value to permit adequate oxygen delivery to the cornea. I also advise the patient to initiate some sort of enzyming routine so the lenses stay free of deposits for longer.
- Follow-up (92012). After you finish the lens fitting process, see the patient after 1 month to assess his cornea. Check for staining with fluorescein dye and rose
If no corneal complications are present and the patient is happy with his lenses, check on him every 6 months. Repeat topography every year for mild or early keratoconus, and every 6 months for advanced stages.
The role of contact lenses
Managing keratoconus isn't limited to fitting contact lenses. In addition to regularly scheduled topography to monitor corneal changes, intermediate exams monitor the progression of the disease as well. This mode of treatment can add substantial income to your practice while you help your patients manage this condition.
Treatment for the Future
ISTA Pharmaceuticals is working on a product with great potential for keratoconic patients. This product, called
Keraform, uses hyaluronidease in a three-part system that:
softens the cornea uniformly
works with rigid contact lenses to reshape the cornea to a more normal shape
stabilizes the corneal surface via topical drops.
The company says that this process provides improved visual acuity and slows the progression of keratoconus so that patients may avoid a corneal transplant.
ISTA completed a Phase I study in blind eyes and is in the process of initiating a Phase IIa trial to begin before the end of this year.
-- By Karen Rodemich
Senior Associate Editor
In many cases, a patient's medical insurance will cover keratoconus contact lens fitting if you send the letter of medical necessity or call for pre-authorization. If it won't, don't prejudge your patient's willingness to pay for it. He'll accept a contact lens fit for keratoconus if you successfully convey the value he'll get. Plus, he'll be grateful for your help in managing his condition.
Not every keratoconic patient will require a contact lens fitting. In fact, I don't always rush early keratoconic patients into RGP lenses because of the long adaptation period. The vision for a patient should be decreased to 20/40 or 20/50 and improvable with RGPs. If a patient knows he'll get better vision with the lenses, he'll be more willing to put up with the initial adaptation period. If a
patient hasn't been fit with RGPs and there's no significant corneal scarring, we have a pretty good idea of how much we can improve his vision.
In my practice, I find that roughly one-third of keratoconic patients are against RGPs. A handful opt for soft lenses, and the rest make do with what vision they get from their glasses.
In either case, these patients are valuable to my practice. Because I'm following these patients for a medical condition, they tend to be more loyal to my practice. In terms of dollar amount, I find that each keratoconic patient I have the satisfaction of helping in turn provides about $250 of additional revenue to my practice. And that's not even counting the contact lens fitting portion, which is about another $800.
Remember, you're the expert in this field, so patients are going to be more open to treatment options. After all, if their best corrected vision with eyeglasses is 20/80 and you get them to 20/30 with contact lenses, they'll be much happier with their lives, more productive at work and they'll feel much safer while driving.
If patients are willing to pay $4,000 for refractive
surgery, then why wouldn't they pay $1,150 to enable them to see better than before?
Dr. Gupta works for Stamford Ophthalmology in Conn. He has no financial interest in any of the products or companies mentioned in the article. You can reach Dr. Gupta at
RE: Patient Name
Stamford Chart No. :12345
I wish to request authorization for treatment of my patient,______________________, who has been diagnosed with the eye condition of keratoconus [ICD-9 code: 371.60]. I examined him in my office on June 20, 2001. Historical and testing information, which led to the diagnosis of keratoconus included the following:
Blurred vision [ 368.8 ]
_______ Corneal striae [ 371.32 ]
_______ Monocular diplopia [ 368.15 ]
_______ Corneal Fleischer's ring
_______ irregular astigmatism [ 367.22 ]
_______ Corneal thinning
_______ Photophobia [ 368.13 ]
_______ Distorted keratometry mires
_______ Corneal scarring [ 371.00 ]
_______ Cone-like corneal steepening
_______ Scissors motion on retinoscopy on topography
Keratoconus is one of the few eye conditions that makes contact lenses a medical necessity. It is an ocular disease in which progressive, degenerative thinning of the cornea (the main refractive surface of the eye) results in a complex, irregular steepening of the corneal surface. Vision is affected by progressively reduced and distorted visual acuity that is not fully correctable with spectacles because of the irregular corneal surface. The primary accepted management to aid vision is with rigid gas permeable
(RGP) contact lenses. By physically resting on the eye, the complex contact lens designs help create a regular optical surface in place of the irregular keratoconic cornea. Often times, this will restore vision to the point where the patient can legally drive a car and perform many job-related activities.
Therefore, I recommend that this patient be fit with RGP contact lenses to achieve the best vision possible. Based on the information provided above supporting a definitive diagnosis of
keratoconus, these devices and associated services are not only the standard of care, but also a medical necessity for this patient.
I am requesting authorization for the following services:
Contact lens fitting and instruction
[ 92070 ] $ 750.00
Contact lens OD
[ V2510 ] $ 500.00
Contact lens OS
[ V2510 ] $ 500.00
Your time and effort on behalf of my patient is sincerely appreciated. If you require further information, please feel free to call me at (203) 327-5808.
Contact Lens Choices for Keratoconus Management
By Ken Daniels, O.D., F.A.A.O., Hopewell, N.J.
Several lenses are available to help us manage
keratoconus. Until recently, rigid gas permeable (RGP) lenses were the most viable option for managing keratoconus because the shape of the distorted cone requires a lens rigid enough to compensate for the uneven corneal surface.
RGPs, I'll traditionally use the first definite apical clearance (FDACL) technique derived from the Collaborative Longitudinal Evaluation of Keratoconus
(CLEK) study. Start with a steep K, work backward to a flatter K until you achieve a minimal apical touch complemented by a small-to-moderate lens diameter.
Soft lenses are generally inappropriate simply because they drape over the cone and don't compensate for the irregular shape of the corneal surface. However, if an early keratoconic patient has reasonably good visual acuity, consider a soft toric lens, although the patient will have a limited time span in using the lens.
- Of the many new lens designs for
keratoconus, Specialty UltraVision's Epicon may be the most promising because it yields a nice balance of comfort and optimal achievable visual acuity. The lens is made from a unique material called
carbosilfocon, originally designed to oxygenate blood during heart and lung surgery.
This material has a high Dk and can cover a larger portion of the corneal surface without risk of edema. It provides comfort close to that of a soft lens, yet provides optics equal to, or superior to, those of an
Even for the more severe cones, the Epicon lens has become a first choice in my practice because of its great comfort, excellent stability and the economical replacement schedule for the patient.
- The SoftPerm by CIBA Vision (Novartis -- Wesley
Jessen) is made from t-butylstyrene silicone acrylate with a HEMA skirt. I use this lens for patients who've never worn a lens before to facilitate comfort and visual acuity. The advantage of the SoftPerm is that it's a soft contact lens for keratoconus patients who don't want surgery and can't tolerate
RGPs. On the other hand, it allows very little oxygen to the cornea.
- The Rose K by Lens Dynamics is more difficult to fit, but because of its computer generated technology, you can customize it to fit the cone. You can use it for severe cones, but it performs much better on early to moderate cones.
- Finally, for patients who require an
RGP, but simply can't tolerate the discomfort, you might try piggybacking. I generally start with a soft lens such as Vistakon's Acuvue Single-Use Lens or CIBA Vision's Dailies, using a -0.50D steep curve that acts as the carrier lens. The
RGP, which is carried on the soft lens, is then designed in the same manner as the
FDACL, yet you can fit it slightly flatter. This helps the patient tolerate the RGP yielding comfort and lens stability.
Dr. Daniels is in private practice in N.J. He's an assistant clinical professor and CLEK investigator at the Pennsylvania College of
Optometric Management, Issue: June 2001