Keratoconus can be devastating to patients due to the impact on their vision with glasses, which may not work due to the irregular astigmatism the condition causes. These visual impacts can be mitigated via contact lenses in most cases, but other treatment options are available.

The diagnosis is often made by the time people are in their mid-30s. According to the AAO’s EyeWiki page (eyewiki.aao.org/Keratoconus ), various papers report the overall incidence as 1:2000; most cases are bilateral.

Even when surgery is required, functional vision can be restored in most cases.

DIAGNOSTIC TESTING

Finding keratoconus clues

While it’s up to the provider to decide if a patient has keratoconus, a number of tests are generally run to assist in making a definitive diagnosis. Often the disease is quite different in each eye, so results that are vastly different on testing is another clue that the patient may have keratoconus. Some of these diagnostic tests are covered by medical insurance and others are not — even when you might think they are medically necessary for diagnosis and treatment.

Refraction

The first test that is often run during an exam is regular measurement of refractive error (CPT code 92015). Often the best-corrected spectacle vision in keratoconus is poor. If this is a Medicare Part B beneficiary, then this code is a noncovered service in all cases. If a prescription is written and the patient has no other insurance (such as vision insurance) to cover it, then your charge for the service should be collected from the patient.

Aberrometry

This test looks for different optical problems than a standard refraction. Eyes with keratoconus are more likely to have these aberrations. Because this is another form of refractive error measurement, code 92015 still fits. Some advocate for the use of modifier 22 (increased procedural service), so your coding would be entered as 92015-22 since this is a way to denote the increased complexity; payer coverage and payment, however, are the same.

Bill 92015 only once, even if regular refraction and aberrometry are both done on the same day.

Corneal topography

This test measures the variations in the curvature of the cornea; some instruments only measure the front surface, while others measure both. A computer crunches the data to make a topographical map. When colors are used, increased curvature (steepness) is shown in hotter colors; cooler colors are flatter.

CPT 92025 (Computerized corneal topography) applies. Coverage is usually present with keratoconus, irregular astigmatism or after trauma or corneal transplant as the diagnosis.

Endothelial cell count (specular microscopy)

Use of this in keratoconus alone before corneal transplant is unusual, but CPT code 92286 applies in all cases. Coverage is likely for post-corneal transplant diagnosis code Z94.7 but may not exist for keratoconus, so be sure and check with that payer before filing a claim. If you need this test for keratoconus but coverage does not exist with this diagnosis, issue the patient a financial waiver such as an Advance Beneficiary Notice of Noncoverage, or ABN, then collect from the patient.

Corneal thickness

Pachymetry is the testing of corneal thickness. One of the hallmarks of keratoconus is the progressive thinning and steepening of the cornea. Corneal thickness can be gauged optically or via a small ultrasonic probe that converts the results into microns. A potentially more reliable and repeatable method is to use an anterior segment optical coherence tomographer (OCT). However, it may take a modification to an existing posterior segment OCT device to make it yield corneal and anterior segment results.

Coding for corneal pachymetry is based on how the measurement is acquired. If this is done via ultrasound, CPT 76514 applies. If it is done optically, then unlisted service 92499 applies. Coverage likely exists for this service from medical payers. Of note, some payers attempt to restrict this to a one-time use related to glaucoma, so you may need to appeal those denials.

TREATMENTS

Several options

Fortunately, surgeons now have multiple treatments they can offer patients who suffer from keratoconus. Following is a review of these therapies, plus their codes.

Contact lenses

Because eyeglasses and soft contact lenses may not provide adequate visual acuity in keratoconus, gas permeable contact lenses usually are the preferred treatment. They can be corneal or scleral lenses. According to a 2018 annual report in Contact Lens Spectrum, the recent trend has been for scleral lenses over standard diameter gas-permeables due to improvement in lens design, easier fitting than in the past and cost decreases (now about $200-$250/lens) in some of the newer designs for scleral lenses. They have durability similar to other gas permeables.

Recently, contact lens manufacturers have introduced custom soft contact lenses specially designed to correct mild-to-moderate keratoconus. These lenses are generally made-to-order and are usually more expensive ($600-$800 for a four pack); they may not last as long as sclerals although they may be more comfortable for the wearer than other gas permeables.

Coding for the fitting is done via CPT 92072 (Fitting of contact lens for management of keratoconus, initial fitting) and is used irrespective of contact lens type. Although this code contains the word “initial,” a provider doing a re-fit in keratoconus can still use this code as clarified by AMA in its September 2017 issue of CPT Assistant. It states: “… If the lens needs to be changed because it no longer fits the patient’s needs, the fitting of new lens is considered an initial fitting …” You can see this is fairly broadly written and applies quite often since keratoconic corneas may change dramatically.

For the contact lenses themselves, you will most likely use the HCPCS codes listed below, although a few payers may demand other codes. The lenses are covered separately when the fitting is also a covered service. If the fitting is not covered, it is unlikely the lens is covered.

Importantly, if a lens for each eye is fitted, be sure and code for each one as the below codes are defined “per lens.” The most common codes are as follows:

• V2531 for scleral RGPs
• V2521 for a hydrophilic soft toric lens
• V2599 for a hybrid lens

Interestingly, vision plans may be far easier to deal with than medical insurance plans and provide better payment and coverage for both fitting and lens services when medically necessary contact lenses are being considered. Additionally, few keratoconus patients wearing contact lenses are Medicare-eligible.

When medical insurance is in play because the patient has no vision plan, prior authorization is highly recommended. Do not just ask for coverage since the cost to provide these services can be very high — be sure to ask about what they will pay. In some cases, the reimbursement would be far lower than costs. Some payers may ask for invoices and allow extra payment, but others will not. Knowing in advance protects your bottom line.

Order lenses on a “per case” rather than a “per lens” basis, as more than one lens is often required. The cost may be nominally more this way, but it will likely save money in the long run; it also allows the provider to change when needed. Additionally, consider having the patient buy a spare pair in case of loss (remember that acuity with spectacles is considerably worse than contact lenses). Lens manufacturers often give a discount on orders for pairs when a successful fit is achieved.

Intrastromal corneal ring segments

These are small, curved devices that a surgeon implants into the cornea to flatten the curve and improve vision. Coverage is likely for keratoconus, but check with the patient’s plan as prior authorization may be required. CPT code 65785 (Implantation of intrastromal corneal ring segment) applies.

Collagen cross-linking (CXL)

CXL is done to strengthen the cornea and potentially prevent progression of keratoconus. The ophthalmologist uses a photosensitizer chemical (riboflavin) and a special UV light to excite the chemical.

If utilized early in the disease, it may allow patients to avoid eventual corneal transplantation. Coverage is likely for “epi-off” CXL (where the epithelium is removed prior to drops and treatment) but it is important to check if “epi-on” CXL (in which the epithelium is not removed) is excluded from coverage. Coding is as follows:

Category III code 0402T applies. The code descriptor is “Collagen cross-linking of the cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)”

HCPCS code J2787 is used for the drug, and it has separate payment in most situations. The code descriptor is “Riboflavin 5’-phosphate, ophthalmic solution, up to 3 ml.” Because the procedure requires the use of 6 ml of solution, submit a total of two units for the drug on claims if all is used. Sometimes, a vial of this drug goes unused, so be sure to note this in the operative note. In that case, separate the drug onto two lines and use modifier JW for the wastage on that claim line, even though payment is the same and will be for the full amount purchased.

Corneal transplant

When symptoms or disease are severe and measures such as contact lenses are unsuccessful, a surgeon may suggest a full-thickness corneal transplant since partial thickness options may be inadequate. Coverage is likely but the codes vary. The codes are:

• 65730 - Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
• 65750 - Keratoplasty (corneal transplant); penetrating (in aphakia)
• 65755 - Keratoplasty (corneal transplant); penetrating (in pseudophakia)

Which of these three codes applies is based on the status (phakic, aphakic or pseudophakic) at the time of surgery.

DIAGNOSIS CODING

Keratoconus is coded on claims as follows:

• H18.611-H18.613 (Stable keratoconus, right/left/both eyes)
• H18.621-H18.623 (Unstable keratoconus, right/left/both eyes)

After transplant in keratoconus, use Z94.7 on claims where coverage exists for the diagnosis of testing, fitting/refitting and lenses.

TO SUM UP

It comes down to three steps. Investigate coverage and payment for lenses and services in advance. Be transparent with patients on their share of costs. Code and document properly. OM

About the Authors

Paul M. Larson, MBA, MMSc, COMT, COE, COC, CPMA, is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Tucson, Ariz.

Brandy H. Sperry, COMT, COE, OCS, is an associate consultant with Corcoran Consulting Group. She has worked in ophthalmology since 1992 and before joining CCG was a practice administrator for a large eye-care practice with three locations in Greenville, S.C.