I have been performing corneal cross-linking for keratoconus since the iLink system (Glaukos) received FDA approval in 2016. Cross-linking showed its benefits for patients with progressive keratoconus as the only way to stabilize the cornea and prevent further progression of the disease. Initially, however, as the procedure was transitioning from private-pay to a covered benefit, coverage was inconsistent and reimbursement rates were sometimes much lower than the cost of the drugs. Perhaps based on those early experiences, many doctors have held on to the misconception that cross-linking is not well reimbursed — even though, in 2024, it actually is quite well reimbursed.

Here, I provide an update on where things stand with reimbursement for corneal cross-linking and strategies my practice has employed to ensure fair reimbursement for the procedure.

Cross-linking codes and reimbursement

Cross-linking is now a covered service for more than 95% of commercially insured patients.

Ophthalmic practices are reimbursed for cross-linking in several ways*:

• Treatment code 0402T pays for the procedure.
• Drug code J2787 covers the cost of acquiring the photosensitizing solutions Photrexa (riboflavin 5’-phosphate ophthalmic solution) and Photrexa Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution). In many cases, payment for J2787 is actually more than the cost of the drug, in order to compensate for staff time and clinic resources to acquire, manage and store the drugs.
• A facility fee may also be paid and may benefit physician owners of the hospital or ASC.
• 92xxx exam codes or 99xxx evaluation and management codes reimburse for pre- and post-treatment exams. There is no global period for cross-linking, so follow-up visits can typically be billed as normal exams, although some insurers may have different requirements.
• 92025 or 92132 can be billed for diagnostic and follow-up topography and tomography imaging of both eyes.

Ensuring fair reimbursement

While cross-linking has been shown to be highly cost-effective for patients, payers and society at large,¹ it is reasonable for practices to ensure that cross-linking is fairly reimbursed as well. To better understand the finances of cross-linking in our practice, we went through a Glaukos Reimbursement Review (RR). RR is a service the company offers to help practices regularly analyze billing practices and reimbursements by payer. The process requires practices to provide the company with Explanation of Benefits forms showing what was billed vs paid for both J and T codes across a range of cross-linking cases. My staff found that gathering this billing documentation could be done easily and that it provided a much clearer picture of overall reimbursement.

We learned that, overall, we were being reimbursed fairly for cross-linking. However, there was a surprising degree of variability in total, average T code and average J code reimbursement. In other words, there isn’t just one single “rate” for cross-linking, as some might imagine. It was helpful to understand our payer mix for these younger patients, which can be quite different from the payer mix for a cataract-age population, for example. Some practices have learned from their RR that they were making coding mistakes or that their EHR was auto-populating fields with the wrong terminology. 

A partial shift to a specialty pharmacy

Through the RR, we were able to identify that a few of our less common payers were significantly under-paying for the J code. In those cases, our normal “buy-and-bill” model was ineffective, because we were spending more to acquire the drug than we were being reimbursed. Because of this, we have switched to a specialty pharmacy model for those specific payers. Instead of purchasing the Photrexa drugs ourselves, we refer the patient to Orsini, a specialty pharmacy that handles the drug acquisition. 

Orsini evaluates patients’ medical and pharmacy benefits and often uses the latter to acquire the drug, then the pharmacy sends it to us for use with that specific patient. The pharmacy handles verification of benefits, pre-authorization and co-pay collection. They interface directly with the patient but also keep in touch with our surgical scheduler, who coordinates scheduling of the procedure based on when the drug will arrive. The whole process takes a few weeks, but we typically have no problem scheduling the patient for cross-linking within our targeted time frame of 4-6 weeks.

For some practices, it may be beneficial to rely almost entirely on the specialty pharmacy route in order to avoid cash outlays for the drug. For us, it makes more sense to mostly stick with buy-and-bill and only turn to Orsini for certain insurance plans.

Reimbursement strategies

Over the years, I have learned three key strategies for ensuring fair reimbursement for cross-linking:

1. Build rapport with payers. Developing a relationship with our carrier representative was essential when we were trying to secure coverage years ago, but it remains an important way to address problems or educate payers about changes. Keep in mind that cross-linking is just one of tens of thousands of health-care services paid for by major insurers. It is not reasonable to expect they will understand everything about cross-linking. Sometimes, it is our job to educate them about the natural course of keratoconus, the efficacy of this typically one-time procedure and the lifetime risks of progressing to the stage of needing a corneal transplant in the absence of cross-linking. Right now, I am educating payers about the urgency of treating young patients with keratoconus. Our largest payer has quite a strict policy for documentation of progression that is reasonable for adults but, in my view, is not appropriate for a 17-year-old patient with obvious keratoconus who has already lost vision.
2. Communicate with referring doctors. Ask referring doctors to send all old refractions, exam notes, topographies, manual Ks and other records they may have to help you document progression (or establish that the eye is now stable).
3. Be clear in your own exam notes. Initially, I would just write “progressive KC” in the chart. I learned that I needed to be more descriptive in identifying how the case meets payers’ criteria. I now write something more like, “Kmax has steepened 1.25 D since June 2023, accompanied by a myopic shift of 2.0 D, meeting two criteria for progression.” Sometimes a claim still goes to medical review, but the review is almost always favorable if I have clearly spelled out progression.

With proper coding and documentation and regular attention to payer variables, cross-linking can be a valuable part of any practice, benefiting patients with keratoconus. OM

Reference:

1. Lindstrom RL, Berdahl JP, Donnenfeld ED. Corneal cross-linking versus conventional management for keratoconus: a lifetime economic model. J Med Econ. 2021;24(1):410-420.

*The reimbursement codes provided in this article are for informational purposes only and do not provide affirmative instruction as to which codes and modifiers to use for a particular service, supply, procedure or treatment and does not constitute advice regarding coding, coverage, or payment. It is the responsibility of providers to determine and submit appropriate codes, charges and modifiers for products, services, supplies, procedures or treatment furnished or rendered.

Kristin C. Bains, MD, is in private practice with Alabama Ophthalmology Associates in Birmingham, Ala. Contact her at kristin.bains@gmail.com. Disclosure: Dr. Bains is a consultant for Glaukos.