A: Close to 30 questions regarding dry eye disease (DED) were submitted to Optometric Management’s Q&A survey. In going through these questions, I selected 10 that represented the most common concerns. Here, I briefly answer those questions; I’ll expand on them in individual columns throughout 2021.

Q: How do I code for in-office procedures, such as amniotic membranes and punctal plugs?

A: Typically, these in-office treatments are covered by insurance, if coded correctly. There are codes used for the procedure of placing the amniotic membrane, as well as diagnosis codes to deem necessity. Some insurances require a prior authorization. Punctal plugs are similar in that they have a procedure code and a related diagnosis code, but unlike amniotic membranes, they rarely require prior authorization.

Q: What is the current coding for DED diagnostic devices, and how can I ensure correct submission to the insurance companies?

A: Medical necessity drives any coding. As long as you can show this, you can bill for the test. There are some nuances when trying to perform multiple tests or similar testing on the same day; this includes linking the procedure code to the correct diagnosis code and knowing the reimbursement rate for each.

Q: For end-stage DED, what further measures can be taken?

A: Depending on the underlying cause of DED, these patients may respond to interventions such as amniotic membrane drops, autologous serum drops, cenegermin-bkbj (Oxervate, Dompé-neutrotrophic keratitis) or in cases of limbal stem cell disease, transplantation.

Q: What are the specific benefits of gland manipulation instruments?

A: With meibomian gland dysfunction, we know that while warm compresses may help and be a good maintenance therapy, they don’t completely express the meibum. We have many great options in our toolbox to assist in expression and should not shy away from utilizing them.

Q: What are the effective protocols for differentiating treatment for mild, moderate and severe cases of DED?

A: Many studies have looked at this, including TFOS DEWS II, Delphi panel treatment recommendations for Dysfunctional Tear Syndrome (DTS), the TFOS Meibomian Gland Dysfunction (MGD) Workshop, etc. By using these protocols, along with our clinical experience, we can find an appropriate treatment for a majority of our patients.

Q: What is the most useful approach to initiating treatment for someone who is not symptomatic, so they understand the importance of adhering to the treatment?

A: A lot of times patients don’t identify their problems as dryness, so it is on us, as the practitioners, to educate them. Utilizing a questionnaire and staff, we can set the stage for the doctor’s discussion of long-term effects of dryness.

Q: How can I engage patients in the importance of in-office treatments?

A: This can depend on the patient’s personality. Most patients respond well when involved in discussion about the cause of their symptoms and an explanation of what the treatments will do. I find that use of measurable DED testing, such as meibography and tear osmolarity, aids in the patient’s understanding and enhances their desire to be involved in treatment.

Q: How can I make sure patients obtain the best DED therapy and that I clear the hurdles with pharmacies regarding getting coverage for medications?

A: This can be tough, especially with ever-changing formularies and coverage. I discuss coupons and how to use them with my patients, when applicable. It is also important to have a good system in place to fill out and submit prior authorizations for medications.

Q: What are your best practices for streamlining treatment?

A: Good discussion, while it can be time consuming, is helpful for patients to understand the treatments ordered. Our practice has a dry eye counselor who helps discuss and set appointments for in-office treatments. This allows for less chair time and an improved confirmation rate of treatment.

Q: How can I get started in treating DED without a huge investment?

A: Using in-house tools, such as DED patient questionnaires (e.g. SPEED, etc.), corneal staining, a slit lamp with cobalt blue filter, a cotton tip applicator for meibomian gland expression and Schirmer’s testing can yield diagnostic information to get you started in managing these patients. OM

DR. KOETTING practices at Virginia Eye Consultants, where she serves as the externship director, and she is adjunct faculty for several schools and colleges of optometry, including Pacific University, MCPHS, Salus University, Southern College of Optometry and the University of the Incarnate Word. She has received consulting fees or honorariums from Oyster Point, Glaukos, Quidel, Horizon, Ocular Therapeutix and Eyevance.