Billing and Coding, ICD-10, and Medically Necessary Contact Lenses

Helpful Take-Away Concepts from an Expert

By Clarke D. Newman, OD, FAAO

On October 1, 2015, the US finally, at long last, moved to ICD-10-CM from ICD-9-CM. ICD-10-CM is required of all providers under the Health Insurance Portability and Accountability Act, or HIPPA.

CMS sent a letter to fee-for-service Medicare providers dated July 7, 2015, to encourage all to providers to use ICD-10-CM: click here.

For a more comprehensive guide, CMS has an entire web page devoted to this subject: click here.

For an ICD-9-CM to ICD-10-CM diagnosis crosswalk for medically necessary contact lens coding: click here.

Your electronic health records (EHR) need to be compliant with ICD-10-CM. You have to teach your staff how ICD-10-CM is different from ICD-9-CM, which means that you have to educate yourself first. You all have to learn the nomenclature. There is no way around it.

For the most part, we changed one set of codes for another. However, there are some real differences. First, the ICD-10-CM codes have more character placements. In ICD-9-CM, there were up to five character placements; in ICD-10-CM, there are up to seven. The first is an alpha character, and the others are numeric. There are three “etiology” placements and an additional seventh character for “obstetrics, injuries, and external causes of injury.” In many of these codes, the last characters in the second and third placements have been reserved by the placement of the letter “X.”

For medically necessary contact lens (MNCL) prescribing, for the most part, you are changing one set of codes to another. For example, in keratoconus, there were three codes in ICD-9-CM. 371.60 was keratoconus, unspecified, 371.61 was keratoconus, stable condition, and 371.62 was keratoconus, acute hydrops. In ICD-10-CDM, keratoconus, unspecified is H18.60, stable condition is H18.61, and unstable condition is H18.62. The sixth character placement is a location placement. This placement is common to almost all eye codes—a “1” means “right eye,” a “2” means “left eye,” and a “3” means “both eyes.” So, a keratoconus, stable, both eyes is coded as H18.613.

For many of the other codes that warrant MNCL prescribing, there is a similar transition for the codes to be more site-specific. So, these changes are basically minor. However, the most significant change from ICD-9-CM to ICD-10-CM will be when you use a bandage lens for the treatment of an injury.

In ICD-10-CM, coding for the “external cause,” “activity,” and “placement” is a requirement. Seriously? Seriously! While, most of the time, this reporting is currently voluntary, it is a very good idea to learn how to make these secondary codings. An in-depth discussion on this subject is beyond the scope of this blog, but a great place to get this information is to go to the AOA webinars on ICD-10-CM.

So, the take-home message is that there are differences between ICD-10-CM and ICD-9-CM, and most of those differences are minor, but some are not. The ICD-10-CM schema is more specific, and increased specificity increases the requirement to keep straight the diagnosis code and the record keeping. If your record says the patient had an abrasion on the left eye, and you code it as a right eye injury, well, guess what happens at an audit?

So, the very first thing you should do is to purchase an ICD-10-CM code book from either the AMA or one of the other suppliers. The AOA has a very good ICD-10-CM reference book available as well. There is a lot to learn here, but reading the code manual is a very good investment of time before you attend the classes. Good luck!

A chart for billing and coding, ICD-10, and medically necessary contact lenses

About Dr. Clarke Newman, OD

Dr. Clarke Newman is a 1986 graduate of the University Of Houston College Of Optometry, and he has been in private practice in Dallas, TX since. His practice specializes in the visual rehabilitation of patients who have had corneal diseases, failed refractive surgeries, or corneal trauma. Dr. Newman is a Past President of the Texas Optometric Association, and is a volunteer advocate for the AOA, and he is a long-time member of the AOA’s Cornea and Contact Lens Section. Dr. Newman is a Diplomate in the Section on Cornea, Contact Lenses and Refractive Technologies of the AAO, and he is a Distinguished Practitioner in the National Academies of Practice. Dr. Newman is also a Fellow in the British Contact Lens Association. He has won numerous awards, including the AOA CCLS Luminary Award for Distinguished Practice and the CLMA GPLI Practitioner of the Year. He writes and lectures frequently on a wide range of anterior segment and contact lens related topics including billing and coding of contact lenses.