Coding for the Procedure

Billing hasn’t changed much for the epi-off procedure since 2019, and currently about 95% of payers have coverage.³ Despite this, adequate reimbursement is an ongoing challenge, making continuous payment and procedural cost-monitoring essential for maintaining a successful, financially feasible crosslinking program. Procurement of the expensive riboflavin drug varies by payer, with some requiring specialty pharmacies and others allowing buy-and-bill. In addition, obtaining and maintaining adequate reimbursement often requires education, additional documentation submission, predetermination or preauthorization, and, in some cases, contract negotiations.

The crosslinking procedure can be performed in either the office or an ambulatory surgery center, with facility coverage for the epi-off procedure in most cases. However, the newer epi-on procedure does not have payer coverage yet, as most payer policies exclude it for its experimental and/or investigational status (i.e., Aetna,⁴ Anthem BCBS⁵).

To better understand the current reimbursement landscape and the financial viability of corneal crosslinking programs, we interviewed Lori Jessen, practice administrator at Colorado Eye Consultants, regarding her practice’s experience with coverage, billing, and overall viability of the procedure.

Ms. Jessen reports that the cost of the drug used for the epi-off crosslinking procedure, Photrexa⁶ (Glaukos), represents the most significant hurdle. In her estimation, the drug’s price has risen approximately 47% over the past 5 years.

This financial strain is not limited to crosslinking alone. With a high concentration of cornea specialists in the state and a referral base spanning Colorado and surrounding areas, offering crosslinking remains essential to the practice’s ability to deliver comprehensive, high-quality corneal care. However, the cornea subspecialty is experiencing mounting pressure as the rising cost of corneal tissue is similarly exceeding reimbursement, further challenging long-term sustainability for several corneal procedures.

Although the epi-off crosslinking procedure has been FDA approved for 10 years, and is covered by most commercial payers, it remains designated as a Category III CPT code (0402T-Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed). Category III codes can present additional administrative hurdles, including variable coverage policies and documentation requirements. However, Ms. Jessen reports that these challenges have been largely mitigated within her practice thanks to proactive payer policy-monitoring and consistent internal staff training. As a result, her practice experiences very low denial and appeal rates for the epi-off crosslinking procedure. 

Coding for the Drug

The drug is a separate and significant issue altogether. Photrexa is billed using HCPCS code (J2787-Riboflavin 5'-phosphate, ophthalmic solution, up to 3 ml). Although most of Colorado Eye Consultants’ commercial payers reimburse the drug essentially as a pass-through expense, Ms. Jessen says 2 of their largest payers for patients requiring this treatment, UnitedHealthcare and Medicaid, do not provide adequate reimbursement for the drug. The practice has had limited success using specialty pharmacies to offset acquisition costs. 

Additionally, the manufacturer’s patient assistance programs are generally designed to support uninsured patients, and typically do not apply to insured patients when payer reimbursement is inadequate. As a result, the financial shortfall is absorbed by the practice, which is unsustainable.

With the recent FDA approval of the epi-on procedure, we discussed potential adoption considerations. Based on information provided by the manufacturer’s representative, the estimated drug cost is approximately $78,000. Implementation would require either trading in their current crosslinking equipment, reportedly with limited trade-in value, or purchasing a new machine. Combined with an estimated 94% increase in drug cost and minimal to no commercial coverage, the practice has elected to defer adoption for now. However, the practice continues to monitor changes to evaluate long-term financial feasibility and patient care considerations. 

Providing crosslinking procedures in an ophthalmology practice is not for the faint of heart. Ultimately, despite its clinical importance, offering crosslinking remains financially challenging for many. Rising drug costs, inconsistent reimbursement, and uncertainty surrounding coverage for new technologies like Epioxa threaten the long-term sustainability of these services. Without meaningful payer support, Ms. Jessen fears access to crosslinking may shift toward higher‑cost academic centers, limiting timely care for patients who depend on this sight‑preserving treatment. OM

Laurie Brown, MBA, COMT, COE, CPC, CPMA, LSSYB is a senior consultant at VMG Health specializing in coding audit and compliance within the Revenue Optimization Consulting Practice. She provides ongoing operational and compliance support to ophthalmology and medical aesthetic practices. Reach her at Laurie.Brown@vmghealth.com.

Brittney Irwin, COT, CPC-A, CEP is a consultant within the Coding Audit & Compliance division at VMG Health (formerly BSM Consulting). In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.

1. Glaukos Announces FDA Approval of Epioxa. Ophthalmology Management. October 20, 2025. https://ophthalmologymanagement.com/news/2025/glaukos-announces-fda-approval-of-epioxa/
2. Bains KC. The cross-linking reimbursement landscape. Ophthalmology Management. August 19, 2024;28(August 2024):E1. Accessed February 27, 2026. https://ophthalmologymanagement.com/issues/2024/august/the-cross-linking-reimbursement-landscape/
3. Aetna. Corneal remodeling (clinical policy bulletin 0023). Aetna; published online. Updated date not indicated. https://www.aetna.com/cpb/medical/data/1_99/0023.html
4. Anthem Blue Cross Blue Shield. CG-SURG-105: Corneal collagen cross-linking. January 6, 2026. Reviewed November 6, 2025. https://www.anthem.com/medpolicies/abc/active/gl_pw_e000230.html
5. Glaukos Corporation. Photrexa Viscous & Photrexa prescribing information. August 2024. https://www.glaukos.com/prescribing-information/photrexa-viscous-and-photrexa/