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.


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.


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.

Practice-Building Opportunity: Add a Dry Eye Clinic

Dry eye is an under-diagnosed and under-treated eye condition. Creating a dry eye clinic serves your patients’ needs—and provides you with a revenue stream.

Over 40% of patients mention dry eye as a primary or secondary complaint. You may not have looked into it yet, but there is a good chance, with the aging population of Baby Boomers and the growing number of people on prescription medications that create dry eye, that this percentage is similar among practices. What’s more, most patients with dry eye complaints are unsatisfied with the treatment they have so far received.

According to Gallup, over 70% of people with dry eye complaints have seen at least three doctors and are still searching for a remedy. In addition, the majority of that 70% still searching for a successful treatment have tried at least three different artificial tear products that have not provided relief. With numbers like these, you should consider to launch a dry eye clinic, devoting one to two days per week to seeing nothing, but patients with dry eye complaints.

High Per-Patient Revenue

Patients who have already tried multiple treatments unsuccessfully are willing to do what it takes to find relief. That attitude is borne out by the per-patient-revenue of dry eye patients.  

Click HERE to download a dry eye calculator that lists the expenses and profits of dry eye treatment so you can determine your potential return on investment.

Delegate Dry Eye Pre-Testing

The key to making dry eye clinics profitable is to streamline the process so you can see as many patients as possible on the days you devote solely to dry eye. For example, your staff can conduct osmolarity (Tear Lab) testing, a five-second test that measures the salt to solution level in the eyes (any reading over 308 is considered an indicator of dry eye). Your staff may also perform testing with an  iCaretonometer which does not require a puff of air or administering drops that could affect the surface of the eye and interfere with the rest of the dry eye examination. Patients are then placed in the exam lane and given a more specific dry eye questionnaire to fill out to assess how the condition is affecting their eye comfort and vision.

After the patient has filled out the questionnaire in the exam lane, they can watch Eyemaginations educational videos with animated graphics that illustrate the condition and pose trivia questions. These videos may also be playing in the reception area. Between the questionnaire and the educational videos in the reception area and exam lane, patients are primed to speak to you when you arrive. They have the state of their condition in mind from the questionnaire and have the beginnings of an education on the topic from the animated videos.

Streamlined Doctor-Patient Time

By the time you get to the exam room, your tasks are limited. After reading the osmolarity measurement, you then can do an assessment of the eyes, expressing the meibomian glands in the lower central and nasal eye lid and then using the slit lamp for an assessment based on your observation. The technician instills a drop of fluoresceine and then lissamine green dye and using a Raton filter you can assess the degree of staining, the tear meniscus height and tear film break-up time. You then should do a fundus examination to rule out eye diseases that can lead to dry eye such as diabetic retinopathy because diabetics have a high prevalence of dry eye disease. You can project the images of the patient’s eyelid glands from the slit lamp onto a flat screen monitor via the TelScreen EyeRes system to show patients a picture of their condition and bring to life what you are explaining to them. You may also run through the Eyemaginations animations related to their specific condition while in the lane.

Code and Bill for Dry Eye

When patients visit your office with medical conditions that they already know cause dry eye-often on referral from their primary care doctor-you are able to bill medical insurance for the visit and services, but when patients present with symptoms such as dry eye-related blurry vision, you would bill vision insurance. The extensive testing using instrumentation also offers an opportunity for billing. For example, in addition to offering patients a literal picture of their condition, the pictures you project onto the slit screen enable you to bill for anterior segment photography when appropriate. With dry eye a condition frequently related to medical conditions a patient may not yet know they have, such as diabetes, it is not uncommon for a vision insurance patient to eventually become a patient whose treatment is billable to medical insurance. You may also able to bill for the TearLab osmolarity test which reimburses approximately $46 for two eyes of testing (The AMA CPT recommends reporting 83861 twice, using the “-59” modifier for the second eye tested to indicate that it is a “Distinct Procedural Service”). Click HERE for a detailed article on coding and billing for dry eye.

A Long-Term Treatment

There is no cure for dry eye and it frequently worsens with age, additional medical conditions and the addition of new prescription medications. Your patients will be served by your long-term care, thereby creating a loyal patient base likely to refer you to friends and family as the doctor who finally provided them with relief.

Fear of Falling Tied to Glaucoma Severity

Visual field (VF) loss resulting from glaucoma is associated with an increased fear of falling, even in people not classified as blind, according to a study published in Ophthalmology. More science needs to be applied to how we train people to walk and to navigate the world. Patients might then be less likely to fall and less likely to bump into things and then eventually be less likely to be fearful, but presently there are no good methods fot that type of training.

The study noted that 50% of people with glaucoma fall over the course of a year, and injuries are more common in this group than in other elderly people. They studied 83 glaucoma subjects with bilateral VF loss, mean age was about 70 years old. All subjects completed the University of Illinois at Chicago Fear of Falling Questionnaire, which includes questions about walking on icy ground, negotiating dark stairs, stepping off a curb, and other circumstances.

Glaucoma was associated with significantly greater fear of falling. This increased with greater VF loss severity. Other variables predicting increased fear included being female, decreased strength and greater comorbid illness.

Long-Term Success of Trabeculectomy May Be High

The performance of trabeculectomy over a 20-year period indicates that this procedure is adequate for controlling intraocular pressure, according to a retrospective cohort study published in Ophthalmology. No previous study has evaluated the long-term efficacy of trabeculectomy and express outcome in terms of complete and qualified success, and blindness factors simultaneously.

Among 330 trabeculectomies performed, 60% of surgeries were classified as complete success, as indicated by a reduction in the intraocular pressure to less than 21 mmHg for high-tension glaucoma or a greater than 20% reduction in intraocular pressure for normal-tension glaucoma without the need for additional medication after 20 years of follow-up. 90% of surgeries were classified as qualified success, as indicated by a reduction in the intraocular pressure to less than 21 mmHg for high-tension glaucoma or a greater than 20% reduction in intraocular pressure for normal-tension glaucoma with the requirement for additional medication after 20 years of follow-up.

Know Your Billing and Coding: Dry Eye

Learn easy billing and coding tips to make dry eye treatment a profitable part of your practice. How often do you hear patients complain about the following: “My eyes are dry,” “My eyes water all the time,” “My eyes feel like there is something gritty in them” or  “My eyes are blurry when I read or work on the computer.” Patients with dry eye symptoms are prevalent in every optometric practice.  In fact, according to the Dry Eye Workshop in 2007, prevalence of dry eye ranges from 5%-30% in people aged 50 years and older.

Long-Term Patients

In many cases, dry eye syndrome (DES) is a chronic eye condition requiring more than the simple recommendation to use OTC artificial tears to relieve symptoms. Often first diagnosed during routine eye exams, DES may often be a chronic eye condition requiring ongoing treatment and frequent follow-up.  Typical DES treatment may include office visits, punctal plug insertion and tear osmolarity testing. Additional tests may include schirmer’s, corneal staining and tear break-up time, however, these are not separately billable procedures but instead included in the office visit.

Typical Treatment Plan–and How to Code for It

A typical patient scenario may look like this:

-Initial office visit 99204/92004 for diagnosis and initiation of therapy and osmolarity test 83861
-One-month follow-up office visit 99213 along with insertion of punctal plugs 68761
-Two-week or one-month follow-up office visit 99213/99212 for punctal occlusion. IMPORTANT: 68761 has a 10-day global period so any visit or procedure associated with DES performed in the 10 days following initial punctal occlusion is included and not allowed to be billed separately.
-Three- to six-month follow-up office visits 99213/99212 to monitor symptoms.

A reminder that the following diagnosis codes support medical necessity for closure of the lacrimal punctum by plug 68761, 370.00-370.07  Corneal ulcer
-370.20-370.21  Superficial keratitis without conjunctivitis
-370.23  Filamentary keratitis
-370.33-370.35  Certain types of keratoconjunctivitis
-371.42   Recurrent corneal erosion
-375.15  Tear film insufficiency
-710.2  Sicca syndrome

Establish Medical Necessity for Punctal Plugs

Also note that most insurance beneficiaries will reimburse for two separate punctum closures 68761 on any given day. As long as medical necessity is documented then closure of two additional punctum may be performed if necessary to alleviate symptoms. In addition to the original short-term collagen plugs, 90-day extend collagen plugs are also available. For patients with year round dry eye symptoms the permanent silicone plugs are most beneficial and may stay in place for long periods of time.

ODs Best Equipped to Treat Dry Eye

Treatment of dry eye patients may vary depending on the severity of symptoms, but remember that DES is a condition affecting millions of people every day and optometrists are in the best position as primary care eye doctors to manage these patients.