Serving the Changing Visual Needs of Women Patients

Providing eyecare that serves the needs of women who are pregnant or experiencing other hormonal changes meets a vital need and projects a family-friendly message.

Women sometimes have eyecare challenges that differ from men due to the hormonal changes that they experience during pregnancy and at other times in their life such as through the use of contraceptive pills and during menopause. High-quality artificial tears and switching to a new silicone hydrogel daily replacement lens will become important to prevent excessive inflammation or irritation.

Many of your patients will experience similar symptoms due to hormonal changes. Here are some key points to consider about keeping women’s eyes comfortable through hormonal changes including pregnancy.

In Exam Room: Educate and Reassure Patient

In order not to assume anything, do not address pregnancy eyecare concerns until a woman has told me she is pregnant or asks about it on her own before then. Reassure the patient that pregnancy usually doesn’t cause major issues with eye health, but for those issues you do see, it usually has to do with contact lens intolerance due to hormonal changes in the tears and ocular tissues (most likely) or minor prescription changes that may or may not be permanent. The biggest concern is the development of gestational diabetes and potential diabetic retinopathy.

It’s good to let them know, however, that breastfeeding may extend the issues, but regardless, the benefits for the baby’s eye development through breast milk are fantastic! There are significant brain development advantages to breast milk. It is common for baby formulas to advertise that their brand offers all the necessary nutrients for eye and brain development. Breast milk is even better than those formulas as it naturally contains all of those nutrients. Since 30 percent of our overall brain function is dedicated to vision, the same nutrients in breast milk that enhance brain function also, therefore, are beneficial to the infant’s vision.

Added Precautions Recommended for Pregnant Patients

Don’t dilate pregnant or nursing women unless there is a prominent need to do so to adequately check the health of the eye (for instance, diabetes, risk of retinal detachment, or any other sight-threatening condition). In those cases, have them use punctal occlusion to limit systemic absorption. Rarely, you would come across situations of red eye/infections.

Conceptive Pills Also Cause Hormonal Changes

Even before women become pregnant, they may be experiencing eye discomfort related to the kind of birth control pills they are taking. If a woman has a sudden change in experiencing dry eye, or notices a pattern of dryness throughout the month, that is a flag to ask questions about what type of birth control she is on (it seems to be better with monocyclic brands than tricyclic because the monocyclic pills provide a steady dose of hormones whereas the tricyclic pills change hormone levels weekly and can be more problematic for SOME women).

Opportunity to Begin Education About Pediatric Eyecare

Become active in the InfantSEE program. Tell your pregnant patients about the program as a “gift to them and their baby” as the comprehensive exam is complimentary. As long as the baby is developing normally, they should have an eye exam in the first six to 12 months, again between ages 3-4, and every year thereafter. If there is a problem, there will be more exams scheduled. You should have a bulletin board in your office dedicated to taking pictures with the infants and then posting them up (with parents’ permission). It’s a great conversation piece and helps to educate others about the program.

Make sure you have the HIPAA Marketing Release Form signed before using marketing materials featuring patients.


Perennial Allergy Relief: A Practice Builder

Spring brings seasonal allergies, but it also is important to provide eyecare for patients with perennial allergies unrelated to seasonal changes. You will be rewarded with loyal patients who let others know of your services.

Allergies related to the change of season in the spring and fall is so common that many think exclusively of it when the topic of ocular allergies comes up. Providing for seasonal allergy patients is essential, but don’t overlook another segment of allergy suffers–those with allergies unrelated to these common factors. Here are key points to keep in mind to serve patients with allergies that don’t go away with the passing of spring or fall.

May Be a Systemic Reason for Allergies

Most nonseasonal, ocular allergies are associated with dust or dust mites, animal dander or mold. Another chronic ocular allergy called vernal conjunctivitis worsens in warm weather, but is not due to typical seasonal triggers such as pollens. Instead it is an IgE mediated mechanism found in some patients who also have a family history of other atopic diseases such as asthma, eczema or hay fever. GPC (giant papillary conjunctivitis) may also result as a form of ocular allergy to long-term buildup of deposits on contact lenses worn for a prolonged period of time. Acute reaction to some forms of cosmetics is also not uncommon.

Bill Medical, Rather than Vision, Insurance

The amount of reimbursement varies from one insurance company to the next, but you would generally receive approximately $90 to $110 for the initial visit and $39 to $65 for each follow-up visit. You should typically see the patients an average of three times to diagnose, begin treatment and follow up until their symptoms are resolved and they are stable, and then again several months later to make sure they are still OK.

A Potentially Significant Group of Patients

The more severe cases are chronic allergies. Chronic allergies often can be inherited and/or the patient has a history of hay fever, asthma or eczema. Patients are typically younger–early 20s or younger. It is more common in males than females. Many of these cases are children. Practicing in the tropics also had an impact with warm weather often worsening the symptoms. Long-time contact lens wearers who wore extended wear lenses without frequent replacement, who then developed GPC, also were common. Middle-age females would account for most of the cosmetic reactions leading to allergies.

Know the Signs of Non-Seasonal Allergies

Most of the time these patients would come in complaining of discomfort and show clinical signs such as moderate to severe injection, minimal to moderate lid edema or just heaviness of their eyelids. Other common signs of  this form of allergies include mucus discharge, itching and/or burning eyes. At times these patients also would experience concurrent rhinitis. Other times they would complain of contact lens intolerance and come in wanting a new contact lens prescription thinking that is what they need.

Prepare to Treat Non-Seasonal Allergies

There is no special equipment beyond the typical instrumentation needed to diagnose this form of ocular allergy. Most of the examination can be done directly and with the aid of a slit lamp. Corneal dyes are often used to aid in the examination.

Understanding the pathology and clinical picture of these conditions and the differential diagnoses is important. Along with taking advantage of ocular allergy learning opportunities at conferences, keeping up with the related medical literature is also extremely helpful.

Educate Your Patient

Helping the patient understand what is happening to their eyes and explaining both the realistic short- and long-term expectations are what most patients want, in addition to the most rapid relief possible. This will provide the patient piece of mind. If there is something the patient can do to improve their situation and prevent issues in the future, such as more frequent replacement of contact lenses (like daily replacement), then explain why this change is necessary and how a change in their contact lens routine may lead to greater comfort.

Vision Impact Institute

Essilor, an international producer of ophthalmic optics, launched an organization dedicated to socio-economic-related vision issues: the Vision Impact Institute. Today’s most widespread disability, impaired vision, affects 4.2 billion people throughout the world, of whom 2.5 billion have no access to corrective measures.

In its quest to achieve better vision for all, the Vision Impact Institute will act as a global connector of knowledge, data and solutions. The Institute’s mission is to raise awareness about the socio-economic impact of poor vision and to foster research where needed, encouraging measures in the field of corrective vision. It will work to ensure that poor vision and the economic implications emerge as a global challenge.
This public health issue has substantial economic consequences at both an individual and collective level: $269 billion in productivity is reportedly lost every year because of impaired vision, even though all the required solutions (eye exams, corrections) are available.

The underestimated economic impact of impaired vision

While one of the most widespread disabilities in the world, impaired vision and its cost are still underestimated in developed and emerging countries: 30 percent of young people in the world under the age of 18 reportedly suffer from uncorrected refractive error, which is often not diagnosed due to lack of awareness or access to care. This proportion rises to 33 percent in the labor force, 37 percent among elderly people and 23 percent among motorists.

The economic impact is significant globally: around $269 billion in productivity is reportedly lost every year, including $50 billion in Europe, $7 billion in Japan, and $22 billion in the United States–even though there are solutions to correct most of these impaired vision cases.
The annual global cost of productivity loss corresponds to providing an eye exam for half of the current world population. Thus, simple measures might drastically reduce the economic consequences of impaired vision and also the social ones, even though the cost, level o f access to care, and awareness differs by country.

How Many of Your Patients Know What Digital Eye Fatigue Is?

You have some digital eye fatigue syndrome education to deliver to patients. 72% of patients are not even familiar with the term “digital eye fatigue,” according to The Vision Council’s VisionWatch Digital Eye Fatigue Syndrome report. Those patients with children will also need an education on the impact of the condition on their children’s eyes, as 37% of patients with children say they are not concerned about it. Interest in digital eye fatigue syndrome in children, however, may be growing. 47% say they are somewhat concerned about the condition affecting their children and 16% say they are very concerned.

1)  Review your verbal communication to patients. Record and listen to your case presentation. Make sure you are not talking over the heads of your patients. The more complex your sentences and the more syllables in your words, the less likely patients are to understand what you are trying to communicate. 2) Review all written communications from your practice to patients. Check your web site, your treatment protocol handouts, your recall communications; make sure everything is built to communicate in a clear an effective manner. Simplify.

Now, does it really surprise you that 72% of patients are not familiar with the term “digital eye fatigue syndrome?”  Wouldn’t this be better communicated to patients as: “Do your eyes get tired when you spend time reading on your tablet or phone?”

Code Correctly for External Ocular Infections


Treating external ocular infections is a practice builder. Coding correctly and processing billing efficiently makes it profitable.

Conjunctivitis, keratitis and blepharitis are treated every day in most busy optometric practices. Knowing how to properly code and bill for these conditions is extremely important if you want to avoid getting behind on your daily schedule of patients. Not knowing correct coding takes additional time to figure it out , and sometimes leads to staffers just throwing their hands up in frustration and not coding at all. For example, consider how easy it is to make the following mistake if your office does not know proper coding for ocular infections:

Correct coding:
Initial office visit for a new patient 99203 or 99204 and follow up visit one day/one week later 99213/92012 with follow up one week/one month later 99212/92012.

Incorrect coding:
Initial office visit for a new patient 99203 or 99204 and follow up visit one day/one week later 99214/92014 with follow up one week/one month later 99214/92014.

Proper Coding Makes Treatment of Ocular Infections a Practice-Builder

Treatment of most external ocular disease is well within the therapeutic level of licensure for all optometrists and is an excellent way to build your practice volume. Treating these conditions ensures that your patients will come to you first whenever they have a red or painful eye. If you properly treat their ocular condition, patients will keep coming back. Lid disease such as blepharitis/meibomianitis can grow your practice significantly.

An abundance of ICD-9 diagnosis codes are available for coding ocular infections due to the multitude of different eye infections that we are able to diagnose and treat. The following is a short list of the more common diagnoses:
375.01 Acute Dacryoadenitis
375.02 Chronis Dacryoadenitis
375.32 Acute Dacryocystitis
375.42 Chronic Dacryocystitis
053.21 Herpes Zoster Keratoconjunctivitis
077.1 Epidemic Keratoconjunctivitis
077.3 Adenoviral Conjunctivitis
372.20 Blepharoconjunctivitis, unspecified
372.30 Conjunctivitis, unspecified
053.21 Herpes Zoster Keratoconjunctivitis
054.43 Herpes Simplex Keratitis
370.01 Marginal Corneal Ulcer
370.03 Central Corneal Ulcer
370.21 Punctate Keratitis
370.40 Keratoconjunctivitis, unspecified
379.01 Episcleritis Periodica Fugax
379.03 Anterior Scleritis
372.00 Blepharitis, unspecified
373.11 External Hordeolum
373.12 Internal Hordeolum

CPT codes most frequently used for external ocular infections mainly consist of office visits coded with 99201-99215 or 92002-92014. Additional testing may include 92285 External Ocular Photography and 87809-QW Adenovirus Detection. Note that to use this code, you must have an adenovirus detector and a CLIA waiver from the government. External ocular photography is used to document the disease and educate the patient on treatment success. Adenovirus detection performed in the office using the RPS adeno detector determines whether the infection is caused by an adeno virus as opposed to a bacterial infection. Knowing the cause of the infection makes choosing the correct treatment plan easier.
Laboratory testing like the adeno detector requires a CLIA waiver if you want to be reimbursed by insurances. The CLIA waiver is obtained by submitting an application along with $150 and allows you to perform a limited number of laboratory tests in your office. Reimbursement is minimal and dependent on the insurance carrier.
Corneal edema is often associated with various forms of keratitis and has a list of ICD-9 codes including the following:
371.20 Corneal Edema, unspecified
371.22 Secondary Corneal Edema
371.23 Bullous Keratopathy
371.24 Corneal Edema due to Contact Lens
CPT codes for additional procedures performed to treat corneal edema include:
68761 Lacrimal Punctal Plug
76514 Pachymetry
92025 Corneal Topography
92071 Bandage Contact Lens
92285 External Ocular Photography
92286 Specular Endothelial Microscopy
Reimbursement for these procedures is dependent on your insurance carrier and varies, so it is important to review your EOB (explanation of benefit) to determine which carriers reimburse and what the payment allowables are.


Do Patients Like to Make Small Talk With You?

Patients prefer some friendly conversation at the start of their exam, according to Jobson Optical Research’s The Waiting Game report. Just under three quarters of respondents (74.5%) said that they think it’s nice when a doctor starts to make small talk about general topics such as their job, kids or the weather. Women (77.2%) prefer it just slightly over men (72.8%) and older respondents preferred it over younger (18 to 34: 70.7%, 55+: 78%). Apparently a little small talk can go a long way.

Be sure to make notes in the patient records about things that are important to patients such as children, pets, jobs and anniversaries. On the patient’s next visit to the office, with targeted small talk you can ask about how the new dog is making the transition now that the kids are away at college. Don’t rely on your memory, use your patient records to help keep you accurate.

Train your staff to add to the patient notes section as well. When they hear a nugget of news that is important to the patient, add it to the record to help keep the doctor informed. Don’t forget to include news such as the death of the spouse or child. Make it a habit for doctors and staff to have access to a computer when reading the paper so that quick notes can be made in the patient records.

Everything you do should be designed to make sure the patient completes your prescribed treatment plan. Showing that you care by sharing details of life that you know about the patient that are important to the patient goes a long way to achieving this goal.

Make the Treatment of Ocular Allergies a Practice Profit Center

Ocular allergies affect millions of Americans—and you can treat their symptoms. Here’s how to code and bill correctly to make this service a profit center in your practice.

The bad news is that ocular allergies affect a large percentage of your patient population. The good news is that ocular allergies affect a large percentage of your patient population.

Allergic conjunctivitis is an ocular disease that optometrists can diagnose and treat. The best news about this condition is that you do not have to invest in any expensive instrumentation besides your slit lamp to care for these patients. In addition, these patients are loyal to your practice because you are alleviating their allergy symptoms and will continue to return every year because allergic conjunctivitis is typically a chronic condition that returns year after year.

Beyond providing care, here is what you (and your staff) need to know about coding and billing for this treatment.    

Diagnosis codes for allergic ocular disease includes the following:
370.32  Limbal and corneal involvement in vernal conjunctivitis
372.05  Acute atopic conjunctivitis
372.13  Vernal conjunctivitis
372.14  Chronic allergic conjunctivitis
373.32  Dermatitis of eyelid, contact and allergic

All of these diagnosis codes are acceptable billing codes for External Ocular Photography 92285 which has an average Medicare allowable of $23 and is a bilateral procedure.  External ocular photography is billable when it is used to measure the progress or deterioration of ocular tissue associated with ocular allergic disease. 

Two Major Categories of Allergic Conjunctivitis

Allergic conjunctivitis is divided into two major categories: seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC). SAC and PAC are triggered by an immune reaction involving a sensitized individual and an allergen. Ideally, if an individual can pinpoint what they are allergic to and avoid it then their symptoms will be minimal. However, if they are experiencing ocular symptoms they may need the care of their optometrist.

Typical symptoms include:
      •    Watery eyes
      •    Itchiness
      •    Sensitivity to light
      •    Redness
      •    Grittiness
      •    Eyelid swelling

The main difference between SAC and PAC is the timing of the symptoms
Patients with SAC experience symptoms for a short period of time. They may be bothered in the spring by tree pollen, in the summer by grass pollen, or in the fall by weed pollen. Generally, their symptoms resolve during other times of the year, especially in the winter. Patients with PAC experience symptoms throughout the year. Instead of outdoor allergens, they have problems with indoor allergens, such as dust mites and pet dander. Seasonal outdoor allergens may worsen their complaints if they are sensitive to them as well.

If a patient presents with allergic conjunctivitis you should attempt to determine whether it is seasonal or perennial to better decide how often you need to see the patient. A good history of previous episodes or evaluating current symptoms will help you decide.