Ophthalmology and Optometry Coding Alert

To take advantage of new reimbursement avenues that silicone hydrogel lenses have opened up, your coding skills have to be up to par. See if you can tap all the revenue streams illustrated in the following case study and follow-up visits.

Zero In on the Complaint

Check out the following E/M coding example from Carla Jean Mack, OD, FAAO, of the Ohio State University College of Optometry and editor of Contact Lens Spectrum and weekly e-mail newsletter Contact Lenses Today.

Scenario: A new patient presents with a corneal abrasion on the right eye. The ocular damage had likely resulted from the use of a soft toric contact lens, Mack says.

The ophthalmologist determined a corneal abrasion diagnosis and prescribed a topical antibiotic ophthalmic solution for the patient. The ophthalmologist fitted a silicone hydrogel bandage lens.

In such cases, a silicone hydrogel bandage lens is used as a splint to support weak areas of corneal perforation, says Jeffery M. Schafer, OD, MS, clinical assistant professor and chief of Contact Lens Services at the Ohio State University College of Optometry.

"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," says Mack.

In the above situation, use the following diagnosis and procedure codes:

First visit: Report a level-two new patient visit with E/M code 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...).

For the lens fitting, report 92070-RT (Fitting of contact lens for treatment of disease, including supply of lens; Right side). Because 90270 includes the supply of the lens, do not report a V code separately. Report 918.1 (Superficial injury of eye and adnexa; cornea) for the diagnosis.

Second visit: The patient returns and requires a reevaluation of the corneal abrasion and therapeutic healing process. Following the exam and assessment, the ophthalmologist fits a new therapeutic silicone hydrogel lens.

Report the correct E/M depending on the level of history, examination, and medical decision making, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. Your ophthalmologist may be able to report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M service.

Don't miss: If the ophthalmologist takes photos, report 92285-52 (External ocular photography with interpretation and report for documentation of medical progress [e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography;

Reduced services). Modifier 52 indicates reduced services because the photos were taken monocularly, as was medically necessary. Once again, report 92070-RT for the contact lens fitting, and 918.1 for the corneal abrasion.

If the patient returns for follow-up visits until the abrasion heals, code the appropriate level of E/M performed as is necessary to reevaluate the patient's condition.

Consider reporting 92310 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia) with an appropriate fee when employing a piggyback system for treating a keratoconus patient. Use this code along with the proper two- or fourmaterial V codes (V2510, Contact lens, gas permeable, spherical, per lens; and V2520, Contact lens, hydrophilic, spherical, per lens), depending on a unilateral or bilateral fitting. Code the appropriate ophthalmological service (920xx, Ophthalmological services: medical examination and evaluation ...) or E/M level (99201-99205) in addition to the contact lens fitting.

Watch out: Medicare considers 92310 a non-covered service and will not pay for this code under any circumstance, says Mac. If contacts lens prescription and fitting service is provided, the ophthalmologist should inform the patient in advance of his financial responsibility.

Key: The lens fitting codes are not only for use with silicone hydrogel lenses, clarifies David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. "Silicone hydrogel lenses have been a welcome addition to anyone's contact lens practice as they offer more treatment opportunities and success, but the codes do not specify that silicone hydrogel products have to be used with them," he says. "Any brand or type of lens you want can be used as a bandage lens. It's left to your professional judgement."

Do this: Whether you are treating an abrasion or keratoconus, check with the insurance company for its policy about second lenses for abrasions, keratoconus, or piggybacking, advises Gibson.