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How to Expand Your Billing Options for Silicone Hydrogel Contact Lens Services
These tips will help you choose the right CPT and ICD-9 codes to bill for corneal conditions.
By Carla J. Mack, O.D., F.A.A.O.

Figure 1: Dilated nasal conjunctival vessels of the right eye (HEMA lens) as compared to nasal conjunctival vessels of the left eye (silicone hydrogel lens).

Silicone hydrogel contact lenses have been a welcome addition to our practices, enabling us to provide healthier lens options to manage our patients' visual and medical needs.

Along with the health and therapeutic benefits, another less obvious benefit has emerged: the opportunity to expand our billing and coding options for silicone hydrogel lens wearers.

In this article, I'll discuss how you can fine-tune your billing and coding skills and give you examples of appropriate codes for a variety of patient cases.

Case 1: corneal neovascularization in a teen

One of my established patients, a 16-year-old girl presented with mild complaints about her distance vision. She was a compliant daily disposable soft contact lens wearer for 4 years. Previous comprehensive annual eye examinations were unremarkable. 

Figure 2: Corneal vascularization of the right inferior cornea (HEMA lens) as compared to corneal vascularization of the left inferior cornea (silicone hydrogel lens).

She reported good visual acuity and comfort with her current soft lenses. I noted her average daily wearing time was now 18 hours, an increase of nearly 8 hours from the previous year. A slit lamp examination revealed 360° of 0.5 mm to 0.75 mm of corneal neovascularization in both eyes that had not been documented at earlier visits. She had moderate myopia of –5.00D.

After a discussion with the patient and her father, I refitted her with silicone hydrogel contact lenses for daily wear.

The patient returned 1 week later wearing her previous hydrogel lens on her right eye, because she lost the silicone hydrogel lens. She was, however, wearing the silicone hydrogel lens on her left eye. The differing appearance of the circumlimbal conjunctival vessels and corneal neovascularization between the two eyes was substantial (Figures 1, 2).

Coding for case 1

In this case, the patient had both medical and vision insurance plans. We billed the first visit to the vision insurance provider after collecting the appropriate copay and documented it using the following procedure and diagnosis codes:

CPTs

92014 — comprehensive, established patient, one or more visits
92015 — determination of refractive state
92310 — prescription and fitting of contact lenses with medical supervision of adaption.

ICD-9s

367.1 — myopia, primary diagnosis
370.60 — corneal neovascularization, secondary diagnosis.

We billed the medical insurance company for the corneal photography performed at the second visit, which documented the changed and asymmetric corneal neovascularization. We used the following codes:

CPT

92285 – external ocular photography

ICD-9-CM

370.60 – corneal neovascularization
Both the comprehensive eye examination and the contact lens fitting may occur over more than one visit.

Case 2: corneal abrasion

A 20-year-old college student arrived for an early morning urgent care appointment complaining of severe pain in her right eye after removing her soft toric contact lens in the middle of the night.

She wore her lenses on a 2-month, continuous wear basis but was unsure of her lens brand or prescribed wearing schedule.

A comprehensive review of systems revealed an otherwise healthy patient. She didn't have allergies or take any over-the-counter or prescription medications.

She did have decreased visual acuity in the right eye secondary to an 8-mm corneal abrasion, which probably resulted from the removal of her contact lens. She had no corneal infiltrates or anterior chamber inflammation at this visit.

I diagnosed the patient with a corneal abrasion, prescribed a topical antibiotic ophthalmic solution with frequent dosing and fit her with a silicone hydrogel bandage contact lens that was FDA approved for therapeutic use.

Then I asked her to return the following day for evaluation. She noticed immediate pain relief with the bandage lens in place.

Coding for case 2: 1st visit

This patient was new to our office, but our medical record documentation supported the following levels of the three components for the patient's chief complaint:

1. Comprehensive history
2. Expanded problem-focused examination
3. Moderate-complexity decision-making

For a new patient, you must have all three components of the three key elements to code at these particular levels. In this case, the expanded problem-focused examination determines the level is 99202 (Table 1).

CPTs

99202 — new level 2
92070-RT — therapeutic contact lens fitting

ICD-9

Figure 3: corneal abrasion, day 2.

Figure 4: corneal abrasion, day 4.

Figure 5: corneal abrasion, day 7

918.1 — corneal abrasion
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.

The contact lens fitting should be reported as 92070 with the suitable –RT or –LT modifier. The contact lens dispensed to the patient needs no further designation (V code), since 92070 by definition includes the supply of the lens.

Coding for case 2: 2nd visit

The patient returned the following day with improved symptoms. To fully assess the cornea, I removed the bandage lens and instilled fluorescein (Figure 3). The abrasion had improved to 6 mm. I applied a new therapeutic silicone hydrogel lens and used the following criteria to code for the second visit in which two of the three components were required for a level (Table 2):

1. Problem-focused history
2. Expanded problem-focused examination
3. Low-complexity decision-making.

CPTs

99213 — established level 3
92285-52 — external ocular photography (The -52 modifier indicates a reduced level of service was performed because it was done monocularly as medically necessary.)92070-RT — therapeutic contact lens fitting 

ICD-9

918.1 – corneal abrasion
This patient returned for several more visits until the abrasion was healed. At each visit, we used similar coding methods (Figures 4, 5).

Plugs and piggybacking

I have successfully fit several of my dry eye patients with silicone hydrogel lenses to alleviate their symptoms.
I measure success in these cases by how much symptoms and redness decrease and contact lens wearing times increase.

When punctal plugs are indicated, I use the surgical code 68761 (Closure of Lacrimal Punctum by Plug) for both collagen and silicone punctal plugs. Because this is a surgical code, denials are frequent when it's coupled with an E&M visit and performed on the same day as the initial evaluation. In these cases, I use modifier -25.

CPT 68761 must be followed by these appropriate eyelid modifier(s):

   E1 — upper left eyelid
   E2 — lower left eyelid
   E3 — upper right eyelid
   E4 — lower right eyelid

This surgical code designates a 10-day postoperative period. If you must assess an unrelated ocular complaint within 10 days post-op, a -24 modifier must accompany the E&M level.

When using a piggyback system, such as pairing a silicone hydrogel lens with a gas permeable lens for a keratoconus patient, consider using CPT 92310 (contact lens fitting and prescription) with an appropriate fee. Use this code in addition to the proper two- or four-material
V codes (V2510 and V2520), depending on a unilateral or bilateral fitting.

Consider using modifier -22 (unusual procedural service) to help clarify a unique case. You can also code the appropriate ophthalmological service (920XX) or E&M level in addition to the contact lens fitting.

Our responsibility

Silicone hydrogel contact lenses have enhanced our practices by allowing us to provide healthier lens options for patients. What's more, we can use them as problem-solvers and therapeutic solutions in certain cases. However, it's imperative that our role as eyecare providers not end with treatment. We also have a legal responsibility to ensure accurate coding and billing that can be justified with appropriate medical record documentation.