March 1, 2021
By Melanie Frogozo, OD, FAAO
Myopia is a disorder of the eye that causes a refractive error. Patients may have axial and/or refractive myopia, and if over -6.00D, an axial length of >26 mm with fundus changes, it is considered degenerative. Significantly, myopia in children is progressive, and its prevalence has achieved epidemic status. The earlier myopia starts, the more severe it is likely to become.
Myopia of any degree is a condition worthy of medical intervention. That is, myopia is not a consequence-free deviation of normal physiology. Even simply correcting for refractive error carries risks and costs, but myopia’s effects are more insidious than just optically correctable blurred vision. Myopia is a pathological disease process that may contribute to or directly cause floaters, glaucoma, posterior staphyloma, myopic maculopathy, retinal detachment, and optic neuropathy.1 The consequences of myopia can make it impossible to achieve best-corrected visual acuity. It may lead to permanent visual impairment.
Both FDA-approved and off-label treatments are available to limit the progression of myopia. The existence of these treatments in the presence of a myopia epidemic makes it imperative for optometrists to prescribe them to all appropriate children. Current myopia management treatment options include soft multifocal (MF) lenses, orthokeratology (OrthoK), and topical low-dose atropine. In order to ensure that patients receive the care they need, practitioners also must know what reimbursement options are available for the various myopia management treatments.
Coding for Myopia
Optometry receives reimbursement for services and materials from traditional medical insurance and managed vision care plans (VCPs). Reimbursement for billing medical insurance is based on providing care to someone who has a diagnosable medical condition under the World Health Organization International Classification of Disease (ICD) 10th edition. The ICD-10 code for myopia is H52.1, and for degenerative myopia, it is H44.2. The H52.1 myopia code is generally not reimbursable, except by Medicaid and VCPs, whereas degenerative myopia is, even by medical insurance. The VCPs reimburse services and materials based solely on refractive necessity. There is no American Medical Association Current Procedural Terminology (CPT) code for myopia management, and no consensus exists on how myopia management strategies should be billed and reimbursed.
Coding Myopia Management Services
It is possible to bill either medical insurance or VCPs for myopia management services. Consider prescribing soft MF contact lenses for myopia management as an example. The medical decision-making and goal of the service (limiting axial length growth and thereby myopic progression) involved in the process is not adequately described by the plan language of the CPT code 92310 for prescribing contact lenses. Therefore, the retardation of axial length growth in children with progressive myopia can be viewed as an unspecified other medical ophthalmological service (92499). Since medical insurance does not cover unspecified services, the burden of payment is shifted to the patient. Alternatively, an argument can be made that the patient receives the benefit of optical correction at distance with the soft MF contact lenses, so billing 92310 with a refractive diagnosis allows for reimbursement from VCPs. In this case, the peripheral defocus that limits myopic progression is just a fortunate side benefit of no concern to the VCP.
The use of OrthoK for myopia management is clearer regarding reimbursement. OrthoK uses nighttime-wear gas permeable (GP) contact lenses to mold the corneal surface, allowing the patient to experience distance vision correction without wearing spectacles or contact lenses during the daytime. Like soft MF lenses, this process also creates peripheral optical defocus that effectively retards myopic progression. OrthoK is considered an unspecified ophthalmological service, so it will not be covered by medical insurance and should be paid by the patient. Likewise, no VCPs cover the OrthoK procedure.
Coding Myopia Management Materials
Suppose the purpose of prescribing a contact lens (soft or GP) is considered primarily to retard the growth of axial length and thereby limit myopic progression. In that case, the lenses may be coded as an unspecified miscellaneous vision item (V2799). This code is not covered by medical insurance or VCPs and becomes the patient’s responsibility. If distance correction is considered the main benefit of soft MF lenses, the code V2522 for refractive hydrophilic bifocal contact lenses may be used for reimbursement from VCPs. Similarly, the GP lenses used in OrthoK are covered by VCPs using the codes V2510 or V2511 for spherical and toric GP lenses, respectively.
Defining Your Own Reimbursement Pathway
Providing myopia management to myopic children is the current standard of care.2 Myopia management naturally fits into optometry’s role as primary eye care providers, and it should be offered to as many children as possible. Optometry is fortunate, at this point, to have several billing and reimbursement options for myopia management services and materials. Suppose your patients depend on getting their primary eye care covered by VCPs. In that case, you could consider treating pediatric myopes with soft MF contact lenses and billing their plan using the 92310 code for their contact lens evaluation and V2522 for the materials. Follow-up office visits at the end of the global contact lens fitting period may then be billed as visits classified as an unspecified ophthalmological service under the 92499 codes. Other diagnostic testing for monitoring myopia progression, such as axial length measurements (76519), may also be billed using the medical diagnosis code of H44.2 toward medical insurance. When offering OrthoK as a treatment, even though the molding procedure is not covered under VCP plans, the GP contact lens materials (V2510 or V2511) may be billed using the refractive diagnosis myopia H52.1. Many VCPs provide a limited allowance toward refractive services and materials, with the remainder to be paid by the patient. Health Savings Accounts, Flex Spending Accounts, and Health Reimbursement Arrangements may cover the residual costs not covered by VCP plans. Medical insurance benefits can also offset the costs in cases where the service codes of 92499 and material codes of V2799 are being used for myopia management strategies.
Topical 0.01% atropine is not FDA approved for myopia management and is not covered by medical insurance or VCPs. The CPT code 92499 could be used to bill the service to medical insurance.
The epidemic of myopia starts in childhood, whereas the effects of high myopia manifest mainly in adulthood. Poor visual performance and retinal pathology due to high myopia are mostly preventable if axial length is kept below 26 mm. Optometrists are ideally positioned to provide myopia management treatments and should seize the opportunity while it exists to differentiate themselves. Barriers to effective treatment include reimbursement, but avenues exist to compensate providers for the services and the materials. While there is no definitive best reimbursement pathway for every practice, the imperative to treat remains.
Melanie Frogozo, OD, FAAO, is the owner of Alamo Eye Care in San Antonio, Texas, where she directs the Contact Lens Institute.
References
- Flitcroft, D.I., et al., IMI – Defining and Classifying Myopia: A Proposed Set of Standards for Clinical and Epidemiologic Studies. Invest Ophthalmol Vis Sci, 2019. 60(3): p. M20-M30.
- Bennett, T., Researchers: Myopia management may become standard of care, in Primary Care Optometry News 2020, Healio News: https://www.healio.com/news/optometry/20200708/researchers-myopia-management-may-become-standard-of-care.
