Follow the appropriate steps to ensure reimbursement

According to results from the 2022 Optometric Management annual reader survey, 95.2% of respondents reported they provide medical care for dry eye disease (DED), and another 44.1% reported they plan to purchase clinical technology related to DED in 2023. With so many ODs treating patients for DED, and the increased threat posed to vision as the condition worsens,¹ its important to understand what is and isn’t reimbursed by insurance.

Although a variety of services are available for patients who have DED, Medicare and other third-party payors pay only for those related to diagnosis, treatment, or management that are considered “reasonable and necessary”² — specifically, care that “meets, but does not exceed, the patient’s medical need.”³

How do we determine what is “reasonable and necessary? The definitive source for evaluation and management of DED is the Tear Film and Ocular Surface Society (TFOS) publication of the 2017 International Dry Eye Workshop (DEWS II).⁴ Below, we will review the TFOS DEWS II recommendations.

The four steps

The TFOS DEWS II recommendations are based on evidence that supports a staged or step approach to management and treatment of dry eye.⁵

Summarized, these four steps are:⁵

1. Patient education, dietary modification, modification of local environment (e.g. humidity, pollution), lid hygiene, use of warm compresses, use of ocular lubricants.
2. Use of non-preserved ocular lubricants, use of tea tree oil for Demodex (if present), tear conservation, overnight treatments, in-office treatment of meibomian glands (e.g. heating treatment, intense pulsed light for meibomian gland dysfunction), prescription drugs to treat DED.
3. Oral secretagogues, autologous/allogeneic serum eye drops, therapeutic contact lens options.
4. Topical corticosteroid, amniotic membrane grafts, other surgical approaches.

The full description of each step, as well as a summary of TFOS DEWS II, can be seen at bit.ly/TFOSDEWSIIsummary .

Treatment restrictions

Within the TFOS DEWS II step recommendations, more advanced treatments, such as amniotic membranes, are recommended only after steps one to three have been shown to be inadequate, contraindicated, or unavailable. During our work with doctors, we found some who skipped steps in the TFOS DEWS II sequence for DED therapy, and therefore, garnered unwanted attention from various payors. Here are some examples:

1. The doctor placed amniotic tissue as a first line treatment for DED before treating the patient with any other therapy, such as artificial tears, ointments, anti-inflammatory agents, punctal occlusion or autologous serum.
2. The doctor performed punctal occlusion at a new patient exam before trying artificial tears.
3. The doctor performed punctal occlusion of four puncta in one session without considering if two lower puncta would suffice to treat DED.

The above examples illustrate an aggressive approach to treating the patient’s DED. In each of the examples, the payors recaptured the payments for services that were deemed not medically necessary.

The gold standard

The TFOS DEWS II guidelines represent the gold standard for professional care for DED. For reimbursement purposes, these guidelines also define reasonable care. A too aggressive approach that does not adhere to step therapy may lead to postpayment review and repayment of funds to the payor. OM

References

1. Dana R, Meunier J, Markowitz JT, Joseph C, Siffel C. Patient-Reported Burden of Dry Eye Disease in the United States: Results of an Online Cross-Sectional Survey. Am J Ophthalmol. 2020;216:7-17.
2. Social Security Act §1862. Social Security web site. www.ssa.gov/OP_Home/ssact/title18/1862.htm Accessed May 2, 2023.
3. Medicare Program Integrity Manual, Chapter 13 §13.5.4. Centers for Medicare & Medicaid Services website. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c13.pdf . Updated Feb. 12, 2019. Accessed May 2, 2023.
4. Craig JP, Nelson JD, Belmonte C, et al. TFOS DEWS II Report. Ocul Surf. 2017;15:802-812.
5. TFOS DEWS II Patient Summary. Tear Film & Ocular Surface Society. www.tearfilm.org/dettnews-tfos_dews_ii_patient_summary/6814_5519/eng/ . Published July 4, 2019. Accessed May 2, 2023.

MS. SPERRY is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext 238.