Medical Model

Treating Ocular Allergies

By ROB Editors

Treating ocular allergies is often the initial entry point to developing the medical model in an optometric practice. Treatments tend to be straightforward, and in most cases you can provide immediate relief to patients who are in discomfort. Treating ocular allergies also creates new opportunities to let patients know about services you provide as well as vision correction options (e.g. daily disposable contact lenses) that provide freedom and comfort for allergy sufferers.

Here’s an overview of coding for the ocular allergy patient office visits.

VISIT 1
In the majority of cases, anocular allergy is discovered during the examination and is not the primary reason for the examination. For coding purposes, there must be a medical reason for he examination, but it does not have to be ocular allergies. Based on the medical necessity for testing and the documentation of testing, the coding would be chosen from this list:

EXAMINATION
92004, 92014, 92002, 92012
To use these codes you must document general medical observation and initiate a diagnostic or treatment plan. The prescription of an anti-allergy medicine meets this criteria.

99202-99204,99212-99214
To use these codes make sure you meet the history, examination and medical decision making documentation criteria.

REFRACTION
92015
Don’t forget to bill a refraction if you performed this test.

TREATMENT PLAN
Have the patient return to office in one week to ensure the treatment prescribed is working appropriately.

VISIT 2
Most often the pateint is improving with the treatment prescribed. Since there is no new problem or complication with an existing problem, you cannot use the 92012 code. Insteadchoose the appropriate code based on your testing and documentation from the 99212-99214 series. Schedule the next visit based on the medical necessity of managing the ocular allergy, the drugrefill dateand any comorbidities that exist.

Advice from the Field
Three eyecare pracrtitioners offer their reflections and suggestions on treating ocular allergies.

Michael Cymbor, OD, FAAO

Nittany Eye Associations State College, PA

COMMUNICATE “FULL SERVICE EYE CARE”
We are a large practice with seven optometrists and five consulting ophthalmologists. We offer cataract surgery, refractive surgery, ocuplasty, contact lenses and medical eye care. We don’t do any advertising specific to ocular allergies, but we continually communicate the idea that we provide full service eye care. That way, if a patient experiences an allergic conjunctivitis episode, they think of us first.

INTERNAL MARKETING
Train staff to screen for symptoms of ocular allergies. Ask, “Have you been taking any over the counter or prescription medications for allergies?” Look for red, watery eyes. If these symptoms can be recognized in the intake process, the doctor is more efficient in the exam.

EDUCATE YOUR PATIENTS
We produced an educational video with slides on ocular allergies that patients view during their exam. Patients often don’t know about ocular allergies. If their symptoms are severe, they will come to us, but if patients have mild symptoms, they may feel they are supposed to feel that way.

KNOW THE TYPES OF ALLERGIES
SAC: Seasonal Allergies Conjunctivitis
–Seasonal allergies may be severe, and symptoms may occur in people who did not experience them previously. With Penn State University here, we see patients who may have lived their whole life in another part of the world, often in a different climate. They come here and experience a spring as never before, and they come to us with very significant allergic symptoms.

PAC: Perennial Allergic Conjunctivitis is distinguished from seasonal allergic conjunctivitis because it lasts all year. The most common cause of PAC is the dust mite.

Vernal Conjunctivitis is a chronic allergy which is prevalent in children, specifically young males that live in warm climates.

Atopic Conjunctivitis is also a chronic allergy however it typically occurs in males between the ages of 30 and 50.

HOW BIG A MARKET
About 25 percent of our patients suffer from ocular allergies in some form. Ocular allergies are on the rise, and it is not clear why. One explanation is the Hygiene Hypothesis: In clean-conscious, industrialized societies, immune systems lose their purpose and go haywire. Those who work or play in closed, dusty environments are more susceptible.

LOTS OF TREATMENTS AVAILABLE
The treatments available have improved greatly. The biggest advance is a drop that can be taken once a day. This increases compliance and cuts down on preservative build up.

USE DAILY CONTACT LENSES
We tell contact lens wearers that pollen can build up on lenses, despite the best efforts to scrub lenses. We commonly shift patients we are treating for allergies into single use contact lenses.

BILLING AND CODING
If a patient presents for medical reasons, you should bill for the initial visit. If they present for a comprehensive eye exam without a medical reason for the visit, and we treat them for eye allergies, no billing of the visit is appropriate. Subsequent visits to assess ocular allergies will be billed to a third party insurance.

TREATING ALLERGIES LEADS TO OTHER MEDICAL AREAS
Treating ocular allergies is a great way to get into medical eye care. The treatment is more straightforward than other conditions, like glaucoma. Once you become proficient and efficient treating ocular allergies, you have a blueprint for treating other ocular conditions. Also, your patients will be that much more inclined to come to you for those conditions.

Michael Cymbor, OD, FAAO, practices at Nittany Eye Associates in State College, PA. To reach him: mcymbor@nittanyeye.com


Michael Mayers, OD

Mayers Eye Solutions
Powell, Ohio

TALK TO YOUR PROFESSIONAL COLLEAGUES
Advertising in local newspapers that you treat ocular allergies doesn’t provide the ROI. I spoke with local pediatricians and general practitioners in our medical complex and let them know that I treat ocular allergies. General practitioners, especially, should refer contact lens patients with allergies to your practice since multiple diagnoses could exist.

UNDERSTAND FAMILY DYNAMICS
Tell your pediatricians and parents that kids won’t let you know that their eye hurt because parents say, “Don’t rub your eyes!” So kids do weird things with their eyes like roll them up into their eyelids for relief. We learn to recognize these symptoms.

I explain the genetic connection: I say, “If one parent has allergies there is a 50 percent change the child does; if two parents have allergies there is a 75 percent chance the child does.”

My practice has two clusters of age groups: 35 to 45 and then kids 5 to 15. Women have a higher incidence of dry eye that may exacerbate their allergies.

HAVE STAFF DISCUSS ALLERGIES
The staff will review the intake questionnaire with the patient when the patient is at the autorefractor or doing visual fields. They specifically ask: “Are you experiencing any dryness, itchiness or red eyes.” Sometimes the patient won’t take the time to fill out the history form, or they skim over the parts about eye conditions. So our staff asks, “Do you use any over-the-counter eye drops?” Patients won’t think to write that down.

PRESENT ALLERGY TREATMENT PROTOCOLS
I begin a baseline allergy treatment with a cold compress on the eyes at night and artificial tears to wash away allergens. In more severe cases I prescribe an antihistamine/ mast cell stabilizer. We discuss environmental factors like changing pillowcases regularly, washing hair at night to remove allergens before laying their head down to sleep, and applying a cold compress at night… Patients want to hear this from the doctor. This personal touch helps to build a practice.

BILLING AND CODING
Most doctors tend to undercode. When I provide basic treatment and do a slit lamp exam, I code 99213. But when I prescribe a medication that I need to monitor, like an antihistamine / mast cell stabilizer, I usually code 99214, which has a higher reimbursement.

For any allergy treatment, I tend to check the patient for reevaluation at one and two weeks after the initial baseline discussion and treatment.

ASK ABOUT LENS COMFORT
I fit a lot of contact lenses, and the number one reason that patients drop out of contact lens wear is comfort. During allergy season, I sometimes switch patients to single-use contact lenses. They tolerate allergies better that way.

Michael Mayers, OD, is a solo practitioner at Mayers Eye Solutions in Powell, Ohio: mayersod@gmail.com.


Troy Flax, OD

Norman Vision Source Normal, Oklahoma

CROSS TRAINING AND ALLERGY AWARENESS
In Oklahoma, allergies are almost a standard issue. We see them all the time. The main thing we do is ask the patient if they are suffering from eye allergies. It sounds simple, butit’s easy to getget caught up in other issues and forget to ask.

We have staff meetings twice a month and always cover case histories. With us, it starts at the front desk and carries over into pre-testing. The staff asks about allergies, and the techs also ask before I even see the patients. Of course, I ask, too, whether it is noted on their charts or not. In the waiting area, we have flyers put outby the pharmaceutical companies, and sometimes a posterboard during high allergy times of the year.

I also treat my staff for their eye allergies, so they can address patient questions from a sufferer’s standpoint. Their testimony can back up the effectiveness of the treatment.

Discussing allergies with pateints might take time, but once you make it a consistent part of the exam, it doesn’t take up that much time. Since wehave the techsdoing it,a lot of this comes out of the prescreening and case history. We also receive a lot of calls for Rx refills, so we know the treatments are working.

COMBINATION THERAPY
I prescribe in advance of allergy season. I am a big fan of combining prescription nasal sprays along with eye drops. They generally work better together than oral medications, and they go right to the source in a couple of minutes, without causing drowsiness or systemic affects. I don’t prefer over-the-counter medications because they are not as strong.

When it comes to physicians writing prescriptions for allergy eye drop medications, optometrists come up short. We are failing to do our jobs if patients wind up going to a minor emergency clinic or their primary care physician, when we could have prevented the problem in advance. About half of my prescriptions are for allergies, followed by antibiotics, and then glaucoma medications.

We’ve been treating allergies for a long time, but we probably got more aggressive about pursuing allergies medically about 12 years ago. It definitely has made a difference. We are now seeing the children of patients we’ve been treating for a while.

Rx AND CODE AWARENESS
When you write out an Rx, it changes your medical decision making and the complexity of the exam. This also permits you to bill higher because you are starting or changing a prescription. It is Level 3–moderate complexity–when you start or change an Rx. OTC meds don’t count in that level.

There are a couple of main codes I use for allergies. One is 372.14. When there is also edema, I use 372.73. As long as you are coding correctly, you shouldn’t have any problems.

If patients come in only because of allergy symptoms, that is a medical visit. That means we can bill their insurance, instead of only the patients.

We have also seen allergy patients with dry-eye syndrome. Allergies interrupt the tear film, and that can cause fluctuating vision, which will cause patients to seek help.

GET A REP
I always take time to listen to reps from the pharmaceutical companies because no one knows their products as well as they do. We might see them as often as every two weeks, especially the ones who have allergy medications. We have an area for the rep to wait for us, so the staff can also talk with them. We also have had sales reps come in to do five-minute presentations for the staff, or lunch meetings with the entire staff.

Because we have so many allergy patients, the reps will pre-print prescription pads for us, so all we have to do is check off the medication required and sign it. Very often, the techs will send the patients in to me with an allergy-related Rx slip already attached to the chart.

POWERFUL PARTNERING
Another reason I advocate writing prescriptions is because it supports the pharmaceutical companies that support optometry. More research and development leads to more effective treatments.

It’s been a mutually beneficial relationship. The drug companies occasionnally do evening continuing education events for us locally, which saves time and money on continuing education. They also sponsor regional and national meetings, which helps us lower the cost for us to attend. In a nutshell, the companies will talk to us as much aswe want to listen to them.

Troy Flax, OD, practices at Norman Vision Source in Norman, Oklahoma: troyflax@yahoo.com.

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