Let’s see if this sounds familiar: A contact lens patient presents with end-of-day discomfort, a fairly common complaint. Generally, the practitioner first changes the type of contact lens or the modality of lens wear, then perhaps the contact lens care solution. Sometimes this approach resolves the symptoms, but rarely does it solve the problem. 

Perhaps it’s a philosophical situation—patients’ contact lenses are not bothering them; their eyes are bothering them and they happen to be contact lens wearers. To me, these would generally be straightforward medical eye encounters. A patient’s primary reason for a visit of this nature would be pain, hyperemia, discomfort, etc. The fact that they wear contact lenses does not change the medical nature of the encounter. 

Coding End-of-Day Discomfort
To make the situation worse, practitioners often think of these encounters as refractive in nature because of the patients’ initial coverage when the lenses were fit. Consequently, they code in refractive terms, rather than performing an appropriate structural evaluation of the ocular surface and coding the appropriate level of office visit commensurate with the patient’s chief complaint—for which the medical carrier is generally responsible.

These visits should be coded for a medical office visit using either the 920XX or 992XX codes (the most appropriate codes based on what was recorded in the medical record and which met the code definition) and billed directly to the medical carrier in accordance with the rules of the patient’s medical plan. That means that you will be collecting a copay or the patient will pay out of pocket in order to meet the deductible. 

Managing the Medical Visit
Regardless of who is the responsible party financially, this visit is generally a legitimate medical encounter. More importantly, you are evaluating the functional patency of the eye and ocular surface prior to determining the refractive solution for the patient. If the patient’s ocular surface is compromised in any way, simply changing the contact lens or the contact lens solution may only be putting a patch on the situation, not truly addressing the problem.

Testing critical components of the eye may be necessary. Perhaps you need to conduct some clinical lab tests such as TearLab (TearLab) or InflammaDry (RPS). But remember, you can perform these tests only if you have your office approved as a Clinical Lab, and an office physician is designated as a Clinical Lab Director. Perhaps you may need to perform meibography, or even prescribe your favorite therapy for lid margin disease.

Far too often, we take the path of least resistance rather than performing the clinically relevant testing and evaluation that the patient requires to truly determine the right diagnosis and treatment algorithm. Contact lens patients represent roughly 34% of a practice’s total patient base. With the specificity of the upcoming ICD-10 system, it’s more important than ever to properly diagnose your patient and document it appropriately. You will benefit from the consistent and correct application of medical eye care guidelines—not to mention a better profit margin.

Send questions and comments to ROcodingconnection@gmail.com.

1. Rumpakis J. New Data on Contact Lens Dropouts: An International Perspective. Rev Optom. 2010 Jan;147(1):37-42.