Keratoconus patients often present optometrists with a great challenge. It can be very difficult to provide clear, comfortable vision without investing considerable chair time.

The second great challenge of keratoconus patients: receiving proper reimbursement. Stories abound about failed keratoconus billing attempts. Medical carriers are hesitant to part with these higher fees for something as routine (in their view) as contacts. (One exception: Vision Service Plan recognizes the medical necessity for this condition.)


Diagnosis and Fitting

Billing problems can arise in both diagnosing and fitting keratoconus patients. Diagnosis is typically suspected during a routine exam, then confirmed with corneal topography. Medical carriers vary considerably in topography reimbursement. Unfortunately, many wont pay for the procedure, regardless of your appeals.

Once you confirm the diagnosis and counsel the patient, finalize your decision to fit the patient in contact lenses. This is the first step where many offices fail to bill properly. The code for bandage lens fitting and supply (92070) is a poor choice for keratoconus fits because the reimbursement$60 to $85 for the fit and lenses, per eyeis a fraction of the proper amount for a case of such complexity.

A better approach: Bill the code for contact lens fitting (92310) and append modifier -22 to alert the carrier to the greater amount of time and complexity for this proceduretriple the usual rate is not uncommon. Expect to submit further documentation to the carrier to justify this higher fee. A letter of explanation including full color topographic maps often fulfills this requirement.

Remember to bill for the lenses separately using the appropriate

V-codes (such as V2513 or V2531, since youll often use a gas permeable extended wear lens). Bill for both soft and GP lenses if performing a piggyback fit.


Refitting and Monitoring

Once the proper vision and comfort criteria are met, the patient can now be considered fit for the contacts. Should complications arise, the most appropriate way to bill for office visits is using the established patient ophthalmologic (92000) or evaluation and management (E/M) (99000) codes.

Never consider a fitting fee to be a global, year-long obligation to provide unlimited service to the patient at no charge. If you refit a patient, and it is not just an incidental revision of the contact lens, then another fee for 92310, 92311, 92312 or 92313 would be an appropriate code to bill along with the appropriate materials V-code or Healthcare Common Procedure Coding System (HCPCS) code for lens supply.

Some special codes are often used to manage keratoconus. These include:

Corneal topography (92025). This is probably the best way to monitor progression of keratoconus, especially using change analysis features of the instrument.

Bandage contact lenses (92070). These can be used when epithelial defects arise.

Anterior segment photography (92285). Use this to follow progression of endothelial folds, scarring, etc.

Endothelial photography and cell count (92286). This is great for following degenerative changes to the endothelial cell layer resulting in therapeutic decisions.

Pachymetry (76514). Use this to monitor progressive thinning of the corneal apex.

Remember to consult your local carriers medical policies for specifics on billing and coding rules.

Contact lenses have been the mainstay of keratoconus treatment for decades. Knowing how to properly bill for the management of this common condition can keep your practice financially healthy as you fight to keep your patients eyes happy and healthy.

Clinical Coding Committee
~John Rumpakis, O.D., M.B.A., Clinical Coding Editor
~D.C. Dean, O.D.
~David Mills, O.D., M.B.A.
~Laurie Sorrenson, O.D.
~Rebecca Wartman, O.D.

Vol. No: 145:04Issue: 4/15/2008