One of the hottest emerging areas of eye care in clinical practice is the management of myopia. Getting reimbursed for services and materials associated with the management of myopia is an evolving field of interest. The provider must remember that reimbursements may come from the patient or the subscribed payor. Therefore, providers must determine how much it costs to provide these services to younger children and adults and charge accordingly if they want to remain profitable.
Just because a subscribed payor, such as an insurance company or a vision care plan (VCP), does not cover a service or material charge, it does not mean that the provider cannot recover payment for these services and materials from the patient. Proper coding and proper billing strategies can make this part of clinical practice.
USING THE CORRECT DIAGNOSIS CODES
Myopia management is the use of medical, contact lens, and spectacle lens treatments to slow the progression of pathological myopic development in children with the goal of reducing the axial elongation of the eye. This reduces the long-term morbidity associated with axial elongation and the management of adults who already have that long-term morbidity.
The International Myopia Institute (IMI) defines pathological myopia as “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.”1
In 2015, the World Health Organization (WHO) recognized myopia as a leading cause of permanent vision loss.2 This recognition basically changed myopia from a disorder to a disease. As a result of the WHO recognizing myopia as a cause of vision loss, the American version of the 10th Revision of the International Classification of Diseases, Clinical Modification (ICD-10-CM) was amended to add pathological myopia on Oct. 1, 2021.3 There is an emerging paradigm that recognizes the medical necessity of correcting early myopic progression.
In addition to the basic refractive errors, which include H52.1—Myopia, ICD-10 added the H44.2—Degenerative myopia codes. Generally, the H44.2 codes follow the IMI definition. Since the Principles of ICD-10 Coding includes coding correctly by using the most specific code available, the provider must now distinguish between “myopia” and “degenerative myopia.” In young children, especially early in the disease, determining which codes are correct can be difficult.
In fact, this dilemma reflects the difficulty of making the basic decision about when to begin myopia management and when to prescribe routinely for emerging myopes. Deciding when to begin such a regimen for a child is beyond the scope of this article. However, it is now necessary for providers to begin to segregate their myopia patients, both young and old, into the H52.2 and H44.2 bins.
Hopefully, the overwhelming majority, if not all, of the younger children for whom the prescriber begins a myopia management protocol will not yet have any of the attending morbidity that is associated with degenerative or pathological myopia. In these cases, there is no need to code the second denominator. One should only select the “H44.21 through H44.23 ‘without status’” codes, and since the overwhelming majority of children have pathological myopic development in both eyes, most of these cases will be billed with the H44.23 ICD-10-CM code.
For older children who might be showing pathological morbidity development and for adults who already show morbidity, the prescriber should use the code that most closely reflects the morbidity seen by selecting the appropriate letter for the second denominator and also the appropriate laterality for the third denominator. Remember that myopia management does not just apply to children. It is incumbent upon all providers to effectively manage all adult pathological myopic patients who might already have the pathology ascribed to the axial elongation that makes this form of myopia a disease in the first place.
It is important, as it is with all disease descriptions in ICD-10-CM, that the proper numerator, in this case, H44, be selected, as well as the proper denominators. In the first denominator place, degenerative myopia is described by the number “2.” So, it is always correct to describe pathological myopia as “H44.2.” In the second denominator place, the provider should place the appropriate letter denomination, if applicable (Table 1).
|WITH CHOROIDAL NEOVASCULARIZATION “A”
|WITH MACULAR HOLE “B”
|WITH RETINAL DETACHMENT “C”
|WITH FOVEOSCHISIS “D”
|WITH OTHER MACULOPATHY “E”
|THIRD DENOMINATOR—LATERALITY: 1 = Right Eye, 2 = Left Eye, or 3 = Bilateral
For example, if the patient had a retinal detachment that was due to axial elongation prior to Oct. 1, 2021, then the correct ICD-10-CM code would have been one of the various codes contained in the numerator H33. That is no longer true if the detachment is the result of axial elongation. The correct code now is H44.2C, followed by the laterality code of “1” for the right eye, “2” for the left eye, or “3” if both retinas are detached. One might also add the appropriate H33 code as well, and append the proper laterality modifier.
PROCEDURE CODES FOR ADULT MYOPIA MANAGEMENT
Proper reimbursement from the insurance companies requires the establishment of medical necessity. That burden is met when a chief complaint is rational to the diagnosis, the use of the most closely matched ICD-10-CM code is used, and the Current Procedural Terminology (CPT) codes that most closely match the services provided and that are rational to diagnosing the current condition are used.
The testing being done must be ordered by the provider, be rational to the chief complaint, be interpreted, and must affect the clinical decision-making to reach medical necessity. Finally, proper documentation should be standard operating procedure. If it is not written, then it is not done when the auditors come knocking.
Currently, caring for adult pathologic myopia management patients falls under the patients’ medical insurance. One might rationally bill an examination to a VCP, but the rules regarding VCP use is that they are for well-patient visits. So, while patients want to use their vision benefits instead of ponying up copayments and unmet deductibles for medical visits (because they are often lower), providers need to make some decisions based on the contracts that they sign with insurance companies. Accepting VCP exam payments for medical examinations likely will not survive audit.
The key here is to communicate with patients so that their understanding and expectations are realistic. Defusing the bomb before it goes off instead of cleaning up afterward is always a good rule of thumb to follow—and is especially true when navigating the boundary between VCP benefits and medical benefits.
PEDIATRIC MYOPIA MANAGEMENT
When most people think of myopia management, they think of preventing axial elongation in children. In that world, there are three basic methods for affecting the prevention of axial elongation. First, there is medical therapy with atropine. Second, there is the use of contact lenses, both center-distance soft lens multifocals and orthokeratology. Third, there is the soon-to-be-approved-in-the-U.S. group of spectacles for myopia management, and several companies who make them are working their products through the regulatory approvals.
How and when to use these options is beyond the scope of this article. They are mentioned solely so that the provider can contemplate how to best monetize these three basic categories of myopia management in children. This point is very important because each of these modalities have significantly different costs to your office.
The basic business practice of determining the “chair costs” of your office is an essential element of knowing what it costs to deliver services to your patients. Your chair cost is the practice gross profit (gross sales minus adjustments and discounts) minus the cost of goods sold minus the net profit (your take-home pay and benefits) divided by the number of patient encounters.4
Once your chair costs are known, one of the first items is to define what services are included in the prospective service charge. When a fast-food chain creates a global charge for some sort of “combo meal,” the chain will decide what products are included. If the services included are not defined in a particular global fee, then one cannot determine how many visits it will take to deliver that set of services.
After defining the service set, determine (a very accurate prediction at first and reassessment in ongoing analysis) how much time is spent with a patient delivering each of these particular services. There are several ways to count time in the office. It is essential to count staff time as well as eyecare provider time. If staff is doing something profitable with patient A, they cannot do something profitable with patient B at the same time.
When counting the number of patient encounters, I count a patient encounter by a practitioner as one encounter, and I count a staff encounter as one-half of a practitioner encounter. For example, if I spend one hour in total delivering a particular service to a patient, and the staff spends one hour in total, and there are four encounters in an hour, then the total is six encounters times the chair cost. That is what it costs to deliver that service to the patient.
Then, on top of that, one must add the cost of materials, such as lenses, spectacles, etc. Finally, add the desired profit from that experience, and that is how most of the business world determines how much to charge for a service.
One of the things that a provider should never do is to ask another eyecare provider what they charge for a service or materials. That is an antitrust violation.5 Most eyecare providers have a poor understanding of their obligations under the antitrust laws. One can especially get into trouble when dealing with a new practice paradigm, as everyone is unsure of the what and the how of setting up a fee schedule.
Make sure to understand the obligations under the Sherman Antitrust Act when navigating the development of an entire fee schedule. This is especially important for newer providers who are unsure of how to perform certain business functions in their practices. However, it is a good business practice to get in the habit of avoiding the legal pitfalls that can be ruinous to your practice.
Basically, there are two paths that one can go down. The first is to charge separately for each visit provided to a patient. The other is to charge some global service fee for a particular group of services. The first path is better for equitability and predictability, in my experience. However, fee-for-service billing for an ongoing program makes cost prediction very difficult. For this reason, the market is gravitating toward bundled, or global, service fee structures.
Parents of myopic children talk to each other online and at school functions, and they come into your office with a preconceived notion of what to expect in terms of services provided and cost layouts. Parents also tend to do a fair amount of “shopping” for the right physician. So, it is important to market this aspect of one’s practice by focusing on your credentials and patient testimonials on what the experience in your office is like.
In my practice, we have developed an annual global fee structure for each of the categories of pediatric myopia management that are currently approved in the U.S.—medical, multifocal contact lenses, and orthokeratology services. When we have a better idea of what will be involved in providing myopia management spectacles, then I will develop a global fee for that category as well.
One might ask how to structure fees when a child is receiving more than one of these treatments. In my practice, I select the higher of the two fee schedules, as you will be doing at least that amount of work. However, providers must determine for themselves, and independently, how and what to charge for their services.
If, after a proper chair cost determination of the fees, the fees are significantly more than the apples-to-apples comparison to those of local competitors, something is wrong; the chair costs may have been miscalculated, there could be an overestimation of the number of visits that are needed to see the patient, or your chair costs are actually higher than those of your competitors. Regardless, this leaves you at a disadvantage and you must adjust accordingly.
When setting a global fee structure, my best counsel is to determine how many visits it takes in your practice, on average, to deliver the predefined set of services, and add one visit. It is important to err on the conservative side when calculating the number of visits. I have found upon review of these numbers, that, at first, I tend to underestimate the number of visits it takes to provide a defined set of services. However, if the number of visits is grossly overestimated, it will skew the global fee and your competitiveness in the marketplace might be imperiled.
Once the service component of your global fees is determined, add in the material fees. If prescribing soft multifocals, it is imperative to completely understand the program requirements of the various lens manufacturers. There are conditions under each type of lens that may affect your price decision-making. For orthokeratology lenses, one needs to know the lens costs and the warranted lens costs to determine how to add material charges to the global service fees. The same will apply to myopia management spectacles when they enter the marketplace.
Parents want a turnkey price for pediatric myopia management, and they have done their homework. So they will balk if there is a significant departure from their ideal scenario. Learn the cost constraints on the material side and keep abreast of changes to these programs over time.
It is also imperative that staff members are fully educated about how everything works—the global fees and what services they cover, the attending materials included in the global fee, and exactly how to navigate the lens company’s program and online interface.
I have my insurance biller handle the finances and the sign-ups of these programs, as it is best for the insurance person to handle these duties. When setting up these codes in an electronic billing system, do not use the CPT codes 92310 through 92317. These codes do not contemplate the services included in these annual agreements. Until these services in the aggregate are covered by either the medical carriers or the VCPs, it is best not to use CPT codes for them.
Regarding the use of VCP reimbursements, make sure to understand the policies of all VCPs regarding the use of contact lenses and spectacles. Currently, the VCPs apply their routine benefits to these services and materials. Bill accordingly. For these types of global fees, medical insurance carriers do not currently cover these services. For the purposes of these plans, one might break out services that would be billable under the ICD-10-CM codes H44.2 and bill them to the patient’s carrier.
For example, if you are billing a global fee for orthokeratology, it is a standard of care to perform corneal topography on these patients. One might bill the insurance carrier the CPT code for topography (92025) to see if the patient can recover the cost of that test. Be mindful of the billing requirements and balance billing limitations of each insurance plan with whom you have contracted. You can foreclose the balance of a global fee if you are not careful. When possible, follow contract requirements, but avoid breaking out these services.
The management of myopia for both adults and pediatric patients is here to stay and rightly should be the purview of primary eye care. To provide these services effectively, it is important to get properly reimbursed. Optimize routines in the office to minimize the number of visits for both you and your staff and maximize the profitability of this practice area.
Do due diligence to properly determine what services should be included in fees for myopia management, and set fees for those services based on a careful determination of chair costs and the proper allocation of time to provide those services. Also, employ and follow the various lens manufacturers’ programs for the products that are being used in myopia management.
Finally, monitor programs for changes in services and chair costs in this current inflationary cycle, and keep track of actual time spent delivering these services. Adjust fees accordingly, but be mindful of what is competitive in your marketplace. Communicate fully and effectively what these programs entail in the office, and market this service to potential patients and their parents. Use your website, social media, and point-of-purchase promotion in your own patient information center to communicate that you provide these services.
Managing myopia, especially for the pediatric patient, can be a very rewarding experience for you, your staff, children, and their parents. Get involved in this practice modality, but code and bill properly. CLS
- Flitcroft DI, He M, Jonas JB, et al. IMI – Defining and classifying myopia: a proposed set of standards for clinical and epidemiologic studies. Invest Ophthalmol Vis Sci. 2019 Feb 28;60:M20-M30.
- The Impact of Myopia and High Myopia. World Health Organization and Brien Holden Vision Institute. 2019 Aug. 6. Available at myopiainstitute.org/wp-content/uploads/2020/10/Myopia_report_020517.pdf . Accessed Oct. 11, 2022.
- American Medical Association. ICD-10-CM 2021. 2020 Sep 20:620.
- Newman C. A Rational Method for Setting Fees, Part 1. Contact Lens Spectrum. 2008 Nov;23. Available at clspectrum.com/issues/2008/november-2008/coding-strategies . Accessed Oct. 12, 2022.
- U.S. Department of Justice. Antitrust Laws and You. 2022 Mar. 21. Available at justice.gov/atr/antitrust-laws-and-you . Accessed Oct. 12, 2022.