The prevalence of myopia and pathological myopia, discussed later, have both increased significantly (Holden et al, 2016). And, practitioners need to know how to handle the coding and billing for myopia management services.

Prior to 2015, the World Health Organization (WHO), in its International Classification of Disease, 10th Edition (ICD-10), defined myopia as an optical condition; this is found in ICD-10-CM, Subchapter H52, titled “Disorders of Refraction and Accommodation.” This schema does not address the pathological morbidity associated with significant axial elongation of the eye (American Medical Association [AMA], 2020).

In 2019, the International Myopia Institute (IMI) proposed a new definition that carves out pathological myopia. The definition reads: “Excessive axial elongation associated with myopia that leads to structural changes in the posterior segment of the eye (including posterior staphyloma, myopic maculopathy, and high myopia-associated optic neuropathy), and that can lead to loss of best corrected visual acuity.” (Flitcroft et al, 2019)

In 2019, in the original ICD-10, Subchapter H44.2, degenerative myopia was expanded to deal with the specific pathologies associated with axial elongation. That being said, in controlling myopia before it ravages the eyes, the diagnostic codes to use for children will be “Degenerative Myopia (H42.21 to H42.23).” Most of the time, a child will have degenerative myopia in both eyes; so, the diagnostic code to use in controlling myopia in children will be “Degenerative myopia, bilateral” (H42.23) (Flitcroft et al, 2019).

Which Code to Use

Coding and billing for myopia management is new, and there is almost no guidance upon which to rely. In the coding for services, there will be a debate about whether or not the Common Procedural Terminology (CPT) 9231x codes contemplate using a lens to control the axial elongation of the eye. My opinion is that these codes do not.

A very rational case can be made that the 9231x codes were promulgated before the concept originated of using a contact lens for controlling the axial elongation of the eye. Additionally, the plain language of the 9231x codes mentions the “optical and physical characteristics,” and the text does not mention controlling axial elongation. These codes certainly do not contemplate the medical management of myopia using atropine (AMA, 2019).

Basic CPT Principles demand that practitioners should select the code for which the plain text of the listed codes most closely matches the service provided. When none of the listed CPT codes rationally match the service being provided, it is correct to use the “Unlisted ophthalmological service or procedure” code (92499). I believe that 92499 is the correct code for the services associated with myopia management.

Using CPT 92499 for the prescribing of contact lenses to mitigate axial elongation has a couple of benefits. First, I believe it to be the correct code, which always reduces the risk of recoupment losses at audit. Second, payors consider the 92499 code to be a non-covered service until medical necessity is established through prior authorization review. That keeps the payors from deciding what these services are worth.

The material codes are straight-forward. When using a GP lens, use the AMA Healthcare Common Procedure Coding System (HCPCS) code V2510 (Contact lens, gas permeable, spherical, per lens). For the hydrogel multifocals, use the V2522 (Contact lens, hydrophilic, bifocal, per lens). Then, specify the appropriate quantity for the time being billed, which is usually an annual supply. CLS

For references, please visit www.clspectrum.com/references and click on document #301.