By Brian Chou, OD, FAAO
Treatingkeratoconus with contact lensescan greatly improve lives–and create strong bonds with patients who can be your best source of referrals. Specializing in this area requires clinical skills, investment in instrumentation, and building a referralnetwork.
Increased screening for keratoconushas greatly helped toidentify keratoconus patients over the past two decades. With new surgical and contact lens treatments available, this translates to greater treatment opportunities. Keratoconus is a distortion of the cornea thatcan progress, especially during adolescence, and neithereyeglasses nor standard soft contact lenses can improve the poor vision caused by this condition.
In my practice,I have built up a keratoconus specialty over time.I care for six to eight keratoconus patients each week, which is more than what an average ECP probably sees in a year. This has become a significant part of my practice, and I encourage othersto develop this specialty if theyhave a strong clinical interest in helping patients. Inorder to develop clinical skills and launch a specialty intreating irregularcorneas,Icompleted a year-long fellowship at UCLA Jules Stein 11 years ago where I cared for many keratoconus patients. You don’t need this type of a background to provide keratoconus treatment, but undergoing a contact lens residency or fellowship provides invaluable experience treating irregular cornea patients. This experience alsoled to having strong referral relationships with other ODs and ophthalmologists.
Treating keratoconusrequires significantly more chair time, and you need to set premium treatment feesto cover that. In our practice, theinitial treatmentfee is$700.Also, your staff must understand coding and billing for this treatmentfor you to get a decent return on your investment in gaining clinical skills and acquiring instrumentation and fitting sets.
ROB Bottom Line: Keratoconus Treatment
Treatingkeratoconus patients requires a great dealof chair time in thesometimes “trialand error” phase of addressing their unique corneal condition. In routine cases, you will see the patient annually.With acute problems and inthe initial treatment stage, you may see patients weekly.Accordingly, you need tochargefor your services.Here are the numbers to make this work.
Fittingfee = $700
CL materials fee = $200 -$800 annually
Follow-up care =$50 -$150 / visit
Hard Asset Investment
Corneal topographer = $15,000
(Other applications: corneal refractive therapy; refractive surgery pre- and post-op examinations)
Diagnostic Fitting Sets
Set = $1,000
Total Investment= $18,000 TO $20,000
Break-evenpoint= 20patients/ Year 1
Help Patients In Need of Services
Since few optometrists and ophthalmologists specialize in keratoconus, you can generate patient visits best by referrals. I’m fortunate to have a number of optometrists, many in retailsettings, refer me their irregular cornea (trauma, scars)patients. Quite a few ophthalmologists also refer me their keratoconus patients for contacts lenses, as well. I’ve probably had over 30 different ECPs refer me their irregular cornea patients. Since it’s estimated that one out of every 500 to 1,800patientshas keratoconus, it is not plausible for every ECP to develop a significant keratoconus practice. But there is great opportunity here if you develop skills in fitting rigid lenses for this condition.Overthe pastseveral decades, soft contact lenses, easily fit, have become a commodity while specialty contact lens practices that fit contact lenses and rigid lenses have become increasingly rare.Ifyou can fitrigid, oxygen-permeable lenses, you have something that differentiates your practice.
Establish Keratoconus Treatment Plan
There are tremendous variations in severity in keratoconus cases, and the amount of care required also varies greatly. In some cases, the disease is so mild that it’s virtually undetectable and eyeglasses and disposable contact lenses are sufficient. In these cases, annual eye examinations are adequate. In other cases where the keratoconus is more severe and causing problems with vision or comfort, the patient may need examinations every week during the contact lens prescribing process.
For many keratoconus patients, the services revolve around contact lens prescribing, typically custom lenses. The contact lens services in mild cases may be no different than a patient without keratoconus, if the prescribed lens is a simple disposable soft lens. But for most keratoconus patients, the usual and customary new contact lens prescribing will carry a global fee over $700, excluding the actual lenses. The contact lenses may range from $200 to over $800 for an annual bilateral supply.
Akereatoconus specialist needs to haveseveraltrial sets of contact lenses on hand, since there is agreat deal of “trial anderror” in addressingthe unique challenges of such patients. You alsoneedto conduct cornealtopography and see the patient repeatedly. Also,the lenses, which are custom-generated, will cost more and need to be replaced at leastannually since corneal conditions in these patients changes frequently. In summary, thefees must be higher than for conventionalcontact lens patents because ofgreater chair time and the higher level of training required for you tobe confident in offeringthisspecialty.
Know Insurance Codes Needed to Get Reimbursed
If you plan to treat keratoconus patients it is crucial that you educate yourself on the needed insurance codes to get reimbursed for your services:
New CPT code for 2012: 92072 (Fitting of contact lens for management of keratoconus, initial fitting).
Note 1: CPT code 92070 (Fitting of contact lens for treatment of disease, including supply of lens) is deleted for 2012.
Note 2: CPT 92310 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia) may be rejected on audit for a keratoconus patient. –ROB editors
Manage Keratoconus Reimbursement
It is critical to knowwhich vision plans cover kereatonus treatment. Some plansrecognize that keratoconus is a medically necessary reason for contact lenses, andthey includethe necessary contact lens specification. Other vision plansalso have requirements for medically necessary contact lenses, but they are usually more stringent and require additional documentation (e.g. reduced BSCVA beyond a certain threshold). I have found that most medical insurances do not provide adequate reimbursement for contact lens services and materials, even with the -22 modifier (unusual service) appended to the 92310 CPT code. The reality is that many medical insurances readily pay for a keratoconus patient to have corneal transplantation more than specialty contact lens services. That is why a practice with a significant irregular cornea specialty may not want to serve on any medical insurance panels. That way, the practice can either service these patients on a self-pay basis, or patients can be balance-billed. Editor’s Note:Check the patient’s plan.Some plans allowbalance billing; othersdo not.
Necessary Investment: Training and Instrumentation
The greatest investment is acquiring the skill for prescribing contact lenses for keratoconus and understanding the condition and newest treatments. Practitioners can get the appropriate clinical know-how through continuing education, through various contact lens coursework at meetings including hands-on workshops. TheSan Diego Specialty Contact Lens Symposium is a good one to attend for those interested in learning more about treating this condition.
A must-have instrument for the specialty contact lens practice is a corneal topographer. A new one can cost $15,000. The practitioner also needs diagnostic fitting sets, which should include a rigid lens design for keratoconus (e.g. Clearion Dual-Hinge by Acuity One), SynergEyes ClearKone (SynergEyes, Inc.), and a scleral lens like the Jupiter scleral lens (Essilor contact lens). These sets typically run about $1,000 each. It is helpful to have several other diagnostic fitting sets too, (e.g., bitoric fitting set, Kerasoft IC (ArtOptical), NovaKone Toric (Alden Optical), Rose-K (Blanchard), etc.). There is such variation in keratoconus that no single lens design works in all cases, hence the need for a wide array of different lens designs. In addition to keratoconus, a corneal topographer can be used for corneal refractive therapy (CRT, Paragon Vision Sciences) and refractive surgery pre- and post-op care.
It is also important for practice staff to be familiar with scheduling and billing for keratoconus patients, and also the know-how to train a patient on the application and removal of specialty keratoconus lenses which may include SynergEyes ClearKone and scleral lenses where the application, removal and lens care is different than usual.
Best Practices of Keratoconus Treatment
Develop strong referral relationships with other ODs and ophthalmologists. Running a viable keratoconus clinic requires access to those patients, which requires referral sources like corneal specialists and ECPs in practice settings that are not set up to manage these cases.In certain communities where referral patterns are already established and there are “go-to” practitioners who see keratoconus patients, it can be difficult to have a viable new clinic for keratoconus.
Gain necessary clinical knowledge. A practitioner who wants to provide keratoconus services needs to be familiar with collagen cross-linking, Intacs, corneal transplants (lamellar and penetrating keratoplasty), familiar with prescribing hybrid lenses like SynergEyes ClearKone, the various RGP designs for keratoconus, piggyback lenses, bitoric RGPs, thick soft contact lenses (e.g. NovaKone Toric, and Kerasoft IC, Flexlens TriCurve Keratoconus),and scleral lenses (not just mini-sclerals but lenses larger than 15.0mm). The practitioner should also have be familiarity with the resources provided by the National Keratoconus Foundation (NKCF). Prescibing for keratoconus is a cerebral endeavor, more so than general routine optometry, which is why I enjoy prescribing caring for keratoconus patients.
Consider necessary chair time. The fee schedule must account for the increased chair-time required for most keratoconus patients. Generally the fees must be higher than other services to be financially sustainable.
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Brian Chou, OD, FAAO, is a partner with EyeLux Optometry in San Diego, Calif. To contact him: firstname.lastname@example.org.