coding matters

Improve Your Dry Eye Coding

An accurate, complete history is crucial for patient care and coding accuracy.

John Warren, O.D.

Many eyecare providers overthink coding and billing when caring for patients who have symptoms or clinical findings indicative of dry eye, especially if the condition warrants further diagnostic and therapeutic care. Often, patients mention their symptoms in passing or you may uncover clinical signs of dry eye during a comprehensive eye examination. Some patients present specifically because of dry eye symptoms.

Making history

The patient history starts when the encounter starts and ends when the encounter ends. Don't be afraid to go back to the history portion of your documentation to add information. Patients often reveal important pieces of information as you move through the encounter.

Also, note all clinical impressions. If you see subtle meibomian gland dysfunction and ask the patient additional questions about ocular comfort (or discomfort), add it to the clinical record. This type of recordkeeping helps substantiate your diagnosis and treatment plan.

Patient education

When I explain dry eye to patients, I often refer to the condition as tear film deficiency, since it's more descriptive of their specific problem in many cases.

Once I've made a diagnosis of dry eye or tear film deficiency, I begin by educating the patient about his condition.

It's also important to prepare patients for potentially frequent follow-up visits. In today's era of high-deductible insurance plans, many patients will have to pay out of pocket, so they need to understand the time and cost required to resolve their ocular complaints.

What's the code?

As of this writing there are no specific CPT codes for typical dry eye testing such as tear film volume testing, evaluation of the tear film with numerous vital dyes or meibomian gland expression. However, there is a new CPT code (83861) for the evaluation of tear film osmolarity, using devices such as the TearLab device (Invetech). It's a monocular code used twice when testing both eyes. Depending on your location, reimbursement from Medicare is about $25 per eye. This test is indicated to establish baseline tear film osmolarity initially, and to evaluate the initial and ongoing effects of treatment.

Choosing which CPT code to use for the “primary” procedure code for each visit is straightforward with no specific requirements for the diagnosis of dry eye. Simply evaluate the history, physical examination and medical decisionmaking for each visit; then choose the code that's most appropriate for that particular patient and his care. Note that some EMR systems will choose the code for you.

You can use special ophthalmic codes when appropriate (See “Key Codes”). To use 92012, the patient must present with a new problem/condition or you must show that his current therapy isn't adequate and/or needs to be modified. Using 92012 for all visits may not be appropriate, especially once the patient is being monitored long term. OM