The influx of new technologies in optometry is expanding clinical capabilities across a range of conditions, from dry eye to neurovisual disorders. The challenge: Their availability often outpaces code creation from managed care. (See “Stay Ahead of Coding Developments,” below.)
This column discusses how to document for such technology.
Know the “Unlisted” Codes
Some technologies (eg, anterior segment optical coherence tomography) have established Current Procedural Terminology (CPT) codes but are not covered by most payors. Other technologies, such as thermal pulsation therapy, intense pulsed light, and neurostimulation, have no specific CPT codes.
To approach coding and billing in these situations, use either 92499, which is defined as an unlisted ophthalmological service or procedure, or 64999, which is the unlisted procedure code for the nervous system. Both codes are typically not reimbursed unless pre-approved by the patient’s insurance, but should be used by the OD in documentation for completeness.
A caveat: The optometrist should never use a CPT code that doesn’t accurately reflect the service performed. Misrepresentation can be considered fraud.
Create Cash Pay Protocols
To start, the OD should assign an internal procedure code and description for the technology. For example, “TP01” could represent thermal pulsation treatment.
Next, the optometrist should set a clear fee schedule for individual sessions or treatment bundles. For procedure tracking and consistency, the OD must make sure to input the code into their electronic health record and billing system.
Now, the OD should provide a private-pay agreement or waiver form. This form should describe the technology, include a statement that the procedure is not covered by the patient’s medical insurance, and that the patient is responsible for the procedure’s cost. I highly recommend the optometrist and/or overseeing staff member initial or sign this area of the form for documentation.
Finally, the form should contain a line at its bottom for the patient’s signature and date to confirm the patient understands the protocol.
All this supports continuity of care and readies the OD, should they become the target of an audit.
A robust cash-based model is comprised of consistent pricing and bundle pricing with clear follow-up visits. Clearly communicating to patients why a technology isn’t covered and how it benefits their eye health can enable the optometrist to offer new technology to patients even when not covered by insurance.
Approach Strategically
Incorporating new technology in optometric care offers significant clinical and business opportunities, but only if approached strategically. This requires understanding when CPT codes apply, creating ethical cash-pay protocols, and documenting thoroughly. As innovation outpaces coding, it’s up to us to lead responsibly by offering modern solutions while protecting the integrity of both patient care and compliance. OM
