Prescribe with the best clinical outcome in mind for OSD patients

I find myself besieged with questions from O.D.s regarding coding, billing and the economics surrounding dry eye disease (DED). One of the most frequent: the “lack of coverage” or the patient out-of-pocket costs for DED diagnosis and treatment.

So I think it fair to ask: Has the sophisticated DED practice come to terms with this issue? Has DED become an true cash-pay profit center within an optometric practice? I would venture to say “Yes.” Is that a bad thing? There are two sides to the story – let’s consider the issues at hand.

COVERED PROCEDURES

Office visits always will be a covered item in the process of diagnosis and treatment of ocular surface disease (OSD). Whether you use a 920XX or 992XX code to describe your services, both will get covered generally irrespective of the ocular surface diagnosis you use. Much of DED testing, such as staining, Schirmer testing, Phenol Red Thread, are built into the office visit and not charged separately. Other diagnostic procedures, such as clinical lab tests for MMP-9 (InflammaDry) and osmolarity (TearLab), are paid off of the clinical lab schedule, provided you are a registered clinical lab via CMS.

Traditional, long-standing therapies, generally, also are covered. Punctal occlusion and pharmaceutical therapies are covered under traditional medical and pharmacy benefits most patients have. However, newer therapies may not benefit from having a CPT code or reimbursement coverage through third party plans. A bad thing, right? Not necessarily, as I will explain.

NEWER THERAPIES

Today, the average deductible in the U.S. hovers between $6,000 and $7,000. (This is in addition to premiums individuals pay, so the cost of their “coverage” may easily be in the $25,000 - $40,000 range annually.) Specifically at the practice level, this means most procedures you do will be “out of pocket” to the patient since the deductible most likely will not have been met. If a procedure or therapy is not covered, there is not a maximum allowable fee to adhere to, or a written-off amount, thus allowing you to charge what you want for the procedure — as long as you charge all parties equally without bias or discrimination.

TRANSCEND THE PAY ISSUE

I hear the voices of clinicians getting louder and louder about the benefit of non-coverage because of the profitability paradigm. While that, in and of itself, may be a good thing, the question arises: Does being a non-covered service limit the doctor (indirectly or directly) in offering said service to the majority of affected patients?

As a primary author of many of the disease economics works written in optometric publications, I find the disparity of “what the economics could be and what the economics actually are” at the practice level is staggering. Are we subconsciously choosing who to and who to not recommend care? I’m convinced this is happening — not with intent or malice — and I would argue the economic facts bear this out.

For me, it’s just another thing to write about. For you, it’s a critical issue for which you have to confront and deal with on a daily basis. I am optimistic our desire to provide the appropriate and optimal clinical care to our patients will always transcend the issue of whether something is covered or not covered, or whether a patient has to pay or not pay. OM

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com.