Coding for Dry Eye
Are you up to speed with the latest coding guidelines for dry eye? Read on to find out how new treatment strategies are expanding your options for maximum reimbursement.
By Mary Pat Johnson, C.O.M.T., C.P.C., C.O.E., and Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., San Bernardino, Calif.

Is your office ready for DES? This article reviews current protocols, including new drug therapies, and provides dry eye reimbursement codes to help you maximize your revenue.

Recognizing dry eye

ICD-9-CM identifies various dry eye conditions, each with differing degrees of severity and prevalence (see "ICD-9-CM Codes Associated With Dry Eye"). DES, which can occur alone or in conjunction with other ocular and systemic conditions, arises secondary to malfunctioning lacrimal glands. Reduced tear secretion disrupts the tear film, causing ocular discomfort. This condition usually develops with age, but also may be associated with inflammatory diseases such as rosacea, Sjögren's syndrome and rheumatoid arthritis. Other external eye diseases, such as herpes zoster and blepharitis, systemic medications that affect tear production or corneal surgery, also can contribute to DES.

Dry eye symptoms can worsen with the use of antihistamines, certain diuretics, antidepressants and other medications. Patients also may experience more severe symptoms with exposure to environmental conditions such as wind, air conditioning or forced-air heating, or during activities that reduce blink rate, such as extended periods of reading, computer work or driving. Just as causes for DES vary, so do the treatment options.

Considering codes

Patients often are diagnosed with DES after undergoing physical examination and diagnostic testing for eye discomfort or vision change. Physical examination usually reveals reduced tear volume or quality, decreased tear break-up time and corneal surface changes.

Because DES is a medical condition, you should submit examination and diagnostic testing reimbursement claims to Medicare or other medical insurance, not to vision insurance, which covers eyeglass and contact lens examinations. Attempting to simplify the code selection process, eyecare professionals often ask, "What code is appropriate for examining dry eye patients?" Unfortunately, there's no single answer. Depending on the condition's severity and the components of the examination, you may choose from a wide variety of evaluation and management (E/M) codes and eye codes (Current Procedural Terminology [CPT] 920xx) (see "ICD-9-CM Codes Associated With Dry Eye").

Documenting dry eye

Regardless of the CPT code you choose to report the exam, basic documentation should include:

• The patient's name and date of service
• A chief complaint or reason for the visit (see "Documenting Chief Complaint")
• An appropriate medical history (relevant to reason for the visit)
• Documentation of all examination elements performed while assessing the condition (be sure to document positive findings as well as pertinent negative findings)
• An order and interpretation for all diagnostic tests performed
• An impression or diagnosis
• A treatment plan or discharge instructions
• Depending on the nature of the treatment plan, you may need to document failure of primary course of treatment.

After determining a patient's chief complaint, you should document his past ocular and general medical history thoroughly, including any factors that could affect the external eye examination. For example, you should ask about:

• History of corneal, refractive or eyelid surgery
• History of exposure to chemicals or irritants
• Contact lens history including type(s) of lenses worn, wearing time and cleaning regimen. Be sure to include brands of solutions and symptoms experienced with contact lens wear
• History of other ocular conditions including injury and infection
• History of eyelid conditions, including Bell's palsy, lid malposition, injury or trauma
• Current medications, chronic conditions, allergies and symptoms of menopause
• Social history, including tobacco use and activities or hobbies that may aggravate symptoms.

Clinical assessment of DES includes measuring visual acuity, examining extra-ocular areas and evaluating the anterior segment with the slit lamp. If you find signs of DES, you may want to devote additional attention to the skin and eyelids, the tear film and the cornea.

Coding consultations

In some instances, patients with chronic or severe DES are referred to a specialist for consultation and possible treatment. The specialist may bill his or her service using the consultation codes (CPT 9924x) as long as all criteria are met. Those criteria, according to Medicare (effective Aug. 26, 1999), include the following points:

1. A request is made for the advice or opinion of the consultant by another physician, a nurse practitioner, a physician's assistant or, in confirmatory consultations, the patient. The request may be verbal or written.

2. The medical record must document a request from an appropriate source, as well as the need for the consultation.

3. The consulting doctor must take the patient's history and perform an examination, usually of an extensive nature. Diagnostic procedures may be ordered separately.

4. The consultant must send a written report of his findings and recommendations to the referring physician to become part of the patient's permanent medical record. The consultant also keeps a copy for his files.

All these criteria must be met for an examination to qualify as a consultation. However, consultation isn't equivalent to transfer of care. Transfer of care occurs when the referring physician cedes responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents acceptance of care in advance.

Whether using office visit codes or consultation codes, higher-level CPT codes generally are reserved for examinations that address very serious or complicated conditions. Use caution when selecting a level 4 or 5 E/M code for DES. These levels of service -- comprehensive and complex examinations -- usually require a dilated fundus examination. The payer may question medical necessity for such an examination on patients complaining of an external eye irritation, such as DES.

Evaluating the tear film

Once you complete your initial patient evaluation, you may need to perform additional diagnostic tests to confirm DES. Schirmer's tear test, which is one of the most common, measures tear production by inserting strips of paper into the lower lid cul-de-sac, whereas other tests, such as tear break-up time, measure the quality of tear composition. Some cornea experts assert the only definitive, objective test for DES is diagnostic staining with either rose bengal or lissamine green drops. These agents stain the conjunctiva in mild DES, indicating significant goblet cell loss. By the time rose bengal or lissamine green begin staining the cornea, patients are likely experiencing vision fluctuation, and will require stronger intervention than artificial tears, such as prescription medications, to improve their condition.

Usually, separate reimbursement isn't provided for these tests; they're bundled as part of the office visit (see "Coding Tear Tests"). However, testing is required to assess the severity of the condition and plan future treatment. A few third party payers may allow separate payment for diagnostic tests under code 92499 (miscellaneous ophthalmologic service), but you should check with your individual carrier before filing a claim.

Topical strategies for treating dry eye

Primary treatment for mild or moderate DES is medical, beginning with artificial tears, gels and, in some cases, lubricating ointments. Patients with persistent dry eye symptoms who don't respond to these primary therapies may benefit from a new FDA-approved prescription medication, cyclosporine ophthalmic emulsion 0.05% (Restasis).

Introduced in 2003, cyclosporine 0.05% safely and effectively improves tear quality and quantity, resulting in rapid symptom relief. Researchers report that patients experienced improvement in photophobia, itching, dryness and blurred vision in the first month of therapy (results from the FDA phase III trial are shown below). Also, during the course of treatment, patients' goblet cells increased 191% over vehicle, demonstrating that cyclosporine 0.05% produces normal, healthy tears that support the ocular surface effectively. (Read about the efficacy of cyclosporine 0.05% in "A Dry Eye Success Story.")

In addition to demonstrated medical efficacy, cyclosporine 0.05% therapy is an affordable option for treating DES. Over 94% of third party claims for cyclosporine 0.05% are being approved with only 5% of claims being denied. The out-of-pocket expenditures for cyclosporine 0.05% are also reasonable, with 62% of patients paying less than $20 and the average co-pay just slightly under $33.

Surgical intervention usually is reserved for patients with more severe symptoms or as a secondary approach when medical therapy doesn't provide relief. Before considering surgical intervention, be sure the chart clearly documents that eye drops, ointments and prescription therapy failed to improve symptoms. Failure can be attributed to:

• Ineffective medication
• Patient noncompliance
• Patient inability to administer topical medications
• Limited financial resources preventing patients from using prescribed medications on an ongoing basis.

Surgical strategies for treating dry eye

Surgical treatment for DES includes punctal occlusion, eyelid surgery or tarsorrhaphy to conceal and protect the cornea. Although some patients do require major procedures, such as tarsorrhaphy or ectropion repair, most patients show improvement with punctal occlusion.

According to the "Optometric Clinical Practice Guideline: Care of the Patient with Ocular Surface Disorders" prepared by the American Optometric Association, inserting punctal plugs is a reasonable course of action after initial medical therapy. Whether you're placing temporary diagnostic collagen plugs or longer-lasting silicone or thermosensitive acrylic plugs, you receive the same reimbursement: A single payment is made for the procedure and the supply on a per puncta basis.

However, to receive reimbursement for this minor surgical procedure you must make sure to include proper documentation on the patient's chart. In addition to the exam, which illustrates indications, your notes should include the patient's consent to proceed, an operative note and some discharge instructions (see "Optimizing Operative Notes"). Although most in-office surgical procedures don't warrant a comprehensive dictated operative report, the operative note should contain enough information so that a reviewer can understand what was done. For example:

• Which puncta were involved?
• What plugs were used, described by type (collagen or silicone), brand and size?
• Did the patient receive anesthesia?

Similarly, discharge instructions are fairly straightforward for this minimally invasive procedure. A short note stating, "Patient tolerated procedure well. Sent home with instructions he shouldn't rub eyes and to call our office if he experiences pain or discomfort" is usually adequate.

Finally, professional liability carriers generally prefer a written consent, but in some cases, the patient's verbal consent is acceptable ("Procedure explained and patient wishes to proceed").

Coding punctal occlusion

The CPT book provides two separate codes for punctal occlusion:

68760: Closure of lacrimal punctum by thermocauterization, ligation or laser surgery

68761: Closure of lacrimal punctum by plug, each.

By definition, you receive reimbursement for these procedures per puncta, not per eye. Medicare's physician fee schedule for participating optometrists allows $216.56 per puncta for 68760 and $181.09 for 68761. These numbers are down slightly from their peak in 2001, but still represent a relatively high reimbursement for this service (see "Trends in Silicone Plug Reimbursement"). When more than one puncta is involved in the same session, the subsequent procedures are reimbursed at 50% of the allowed amount, consistent with Medicare's multiple surgery rules. For example, if the two lower puncta are occluded with plugs at the same time, then Medicare reimbursement is $181.09 for the first punctum and $90.55 for the second punctum, minus applicable copayment and deductible. Reimbursement rates for commercial and private insurers vary, but traditionally have been comparable.

Some patients require punctal dilation to facilitate plug insertion, prompting practitioners to ask whether this is a billable service under the Medicare program. The National Correct Coding Initiative (NCCI) edits, which update payment rules quarterly, bundles punctal dilation (68801) with the insertion of punctal plugs (68761). (See "Current NCCI Bundles.") Some carriers also have published local policies with additional limitations.

Medicare no longer allows additional reimbursement for punctal plugs, regardless of the type you use. Instead, plug cost is bundled with reimbursement for the surgical procedure. A few commercial carriers make separate payment for the cost of the plugs using CPT code 99070.

According to Medicare Part B Extract and Summary System (BESS) data for 2002, punctal occlusion with plugs (68761) is the fourth most commonly performed ophthalmic surgical procedure. Optometrists performed this procedure 114,000 times on Medicare beneficiaries, or two times for every 100 eye examinations in this population.

The factors that contributed to the rapid growth of punctal occlusion in the Medicare program include:

• Many beneficiaries with DES
• Widespread dissatisfaction with artificial tears
• The efficacy of punctal occlusion with plugs
• Relatively safe and simple office procedure
• Attractive reimbursement.

Any time payers see a rapid growth in payments, scrutiny of the claims is sure to follow (for a worst-case scenario, see "Greed Surpasses Need"). Look for a possible increase in audit activity for CPT code 68761 as payers verify they're reimbursing medically appropriate procedures.

Exploring your options

Dry eye syndrome is a complicated disease, presenting eyecare professionals with clinical, coding and reimbursement challenges. You can avoid many common obstacles and increase your revenue by using treatment protocols reasonably, adhering to community standards of care and remaining cognizant of claim submission and reimbursement protocols.

A Dry Eye Success Story

This postmenopausal woman has a 5-year history of dry, scratchy, burning eyes. Past medical history is notable for mild hypertension and depression treated with irbesartan (Avapro) and citalopran (Celexa), respectively. Initially, she reported relief with artificial tears, but over the past year she began experiencing constant discomfort, despite hourly application of artificial tears. Superficial punctate keratitis. (Photograph courtesy of Calvin Roberts, M.D.) Physical examination revealed BCVA of 20/25 and mild superficial punctate keratitis (SPK) inferior to the central corneal apex in both eyes (see image above). Dry eye syndrome (DES) was confirmed by Schirmer's test and the presence of bilateral punctate staining at the limbus at 4 and 8 o'clock with rose bengal. The patient was treated initially with lower punctal plugs and hourly applications of artificial tears, but she returned 2 weeks later complaining that the burning sensation was much worse. Examination revealed no change in the central SPK, but increased rose bengal conjunctival staining. The punctal plugs were removed, and the patient began using cyclosporine ophthalmic emulsion 0.05% (Restasis) twice a day while continuing to apply artificial tears. After using cyclosporine 0.05% for 1 month, the patient reported improved clinical symptoms. Decreased SPK and rose bengal staining confirmed clinical progress. The patient continued using cyclosporine 0.05% for the next 3 months, after which her SPK and burning discomfort resolved. The patient reported that her use of artificial tears had been reduced to just three times per day.

Greed Surpasses Need

An eager eyecare professional initiated a marketing plan to attract and aggressively treat young patients with symptoms of dry eye. Anxious to build his practice as rapidly as possible, he ignored the well-intentioned advice offered by his colleagues and professional association fellows. Each new patient was asked to complete a Dry Eye Symptom Questionnaire, regardless of his chief complaint. Subsequently, many patients underwent occlusion of all four puncta, first with collagen plugs, then with silicone plugs. Initially, the enterprising eyecare professional enjoyed soaring revenue secondary to favorable commercial insurance payment rates and increased procedure volume. After a time, however, third party payers began requesting medical records for prior claims and requiring authorization before treatment. As accounts receivable grew and pressure mounted from several large payers seeking to recoup payments, the doctor became concerned. After almost 2 years of vigorously promoting dry eye treatment, the doctor discovered that no third party payer would accept his claims for treating dry eye. What can we learn from this experience? Extraordinary utilization of any CPT code always carries an element of risk. Deviation from accepted standards of care raises concerns about the medical necessity of the treatment. You can avoid excessive scrutiny by: Following current treatment protocols for DES, beginning with a pharmaceutical regimen Documenting the medical necessity of punctal occlusion, including the failure of artificial tears Making sure your chart documentation is thorough and complete.