BUSINESS

  CODING STRATEGY

ADDRESS DISCOMFORT

CONTACT LENSES MAY NOT BE THE ISSUE

JOHN RUMPAKIS, O.D., M.B.A.

CONSIDER THE situation: “Doctor, I’m here today because my contact lenses aren’t working any more. I can’t make it through an entire day without feeling like I want to grind my eyeballs out of my head!”

“No worries,” you say. “It is fairly common for contact lens wearers to experience discomfort; I will change the contact lenses that you are wearing to a newer material and it should solve the problem.”

IDENTIFY THE PROBLEM

Numerous recent studies, including one that I authored in January 2010’s Review of Optometry, have demonstrated that the No. 1 reason for contact lens dissatisfaction is discomfort. It may be easy to change the patient’s lens or solution to address this, but it is also important to discuss ocular surface disease (OSD), another possible cause of the discomfort. Most of us tend to want to change the lens or the solution, rather than discuss with the patient that the cause of the problem most likely is some form of OSD, and “I have to bill your medical insurance for it,” “You haven’t met your deductible,” “I’m not on your panel,” and “I want to give you a discount because I can’t justify my own fees,” etc.

Worse yet, many of us would not even charge the patient for this visit because we feel badly that the patient is having a problem and it fits into our “annual contact lens package.” But — being able to properly differentiate between cause and effect is critical in knowing how to provide and code for the proper care that you need to provide.

CALL IT WHAT IT IS!

Let’s look at another approach that just might make more sense, both because it that is consistent with medical care policies and it is appropriate by today’s clinical standards. On a philosophical level, the patient’s contact lens is not bothering him, his eye is bothering him and he happens to be a contact lens wearer. The patient’s primary reason for the office visit would be pain, hyperemia, discomfort, etc. The visit is medical; the fact that the patient wears contact lenses does not change that. Therefore, this visit would be coded for a medical office visit using either 920XX or 992XX. (Choose the most appropriate code based on what was recorded in the medical record, and the definition of the respective code.) Bill the visit directly to the medical carrier in accordance with the rules of the patient’s medical plan, whether or not he or she has met his or her deductible!

Yes, you will be either collecting a co-pay or the patient may be paying out of pocket to meet his deductible. Regardless of who is financially responsible, this visit is generally a legitimate medical encounter and not a freebie built into an “annual contact lens package.”

One caveat: Some managed vision care plans require, as part of its contract, a single follow-up exam after the initial fit or refit, generally within the first 30 days of billing the 92310 contact lens fitting code.

BOTTOM LINE

Contact lenses are a large part of most optometric practices, and contact lens discomfort and drop out is fairly prevalent. Appropriately diagnose the problem and correct it, whether it is by prescribing a pharmaceutical agent, performing in-office procedures or instituting proper lid hygiene. This also will allow you to create a proper medical record that demonstrates the medical necessity for your services. You may still change the contact lens material, modality or solution. But it will be based upon substantiated clinical evidence. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.