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Schedule dry eye workup after initial examination
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Coding for dry eye workups depends on a variety of factors, including the level of history taking, exam and medical decision-making, and whether the patient is established or new. “I would strongly suggest that these workups be performed on a subsequent visit to the patient’s initial eye exam and not as a part of it,” D.C. Dean, OD, a practitioner at New Mexico Eye Care in Albuquerque, told Primary Care Optometry News. “Elements of this kind of visit should include a detailed history of the patient’s dry eye-related symptoms.”
Facets of a dry eye workup
Definitions of what constitutes a dry eye workup may vary, but certain elements are recognized as essential.
“I consider a dry eye workup to consist of additional specific tests that come after a comprehensive eye exam,” John M. B. Rumpakis, OD, MBA, founder of Practice Resource Management Inc. in Lake Oswego, Ore., said in an interview. “So obviously, practitioners would do visual acuities and a thorough exam of the lids and adnexa. They should also do a thorough corneal exam, looking for any staining, ulcerations or scars that would affect the surface quality.”
Dr. Rumpakis said he also advises looking at the tear meniscus and the underside of the eyelids as well as looking for lid wiper epitheliopathy. The patient’s tear production should also be qualified and quantified.
“There are a few methods practitioners might use to do this,” he said. “There is the phenol red thread test, traditional tests such as Schirmer’s, with or without anesthetic, and the lissamine green test,” he said.
Dr. Rumpakis summarized the three essential components of a dry eye workup to be quality of tears, quantity of tears and the condition of the corneal surface and lid surface.
“You want to know how the physiology is set up to accept the tears,” he said. “Always look at all three components. That is what the dry eye workup consists of.”
Dr. Rumpakis said the dry eye workup and subsequent care in addition to the comprehensive examination could be coded with either the 920XX or 992XX Current Procedural Terminology (CPT) codes. However, he prefers to use the 992XX codes because of their greater acceptance by medical insurers.
“It is important, then, to clearly document and score the history, examination and medical decision-making used to evaluate the patient,” he said. “Clinicians should use the 1997 Evaluation & Management Guidelines produced by the Centers for Medicare and Medicaid Services as their guide for properly fulfilling the examination requirements.”
Dr. Dean said the dry eye exam should include a detailed history of the patient’s dry eye-related symptoms. He said most insurers’ policies require exam elements that include the following:
- results of Schirmer’s test or equivalent
- tear breakup time
- slit lamp exam, most often with use of vital stain, to establish evidence of corneal decomposition
Dr. Dean explained the need for each of these exam elements.
“The first two tests are to establish if there is a lacrimal gland insufficiency (375.15),” he said. “The last element is looking for punctate keratitis (370.21) and/or keratoconjunctivitis sicca (370.33). Consider using the 99213 Evaluation & Management code for mild to moderate dry eye and the 99214 code for more severe cases.”
According to Scot Morris, OD, FAAO, a private practitioner at Eye Consultants of Colorado, a thorough inquiry into the patient’s systemic conditions is also quite helpful.
“I would suggest that doctors use a more detailed patient questionnaire to sleuth additional information on dry eyes, allergies, systemic disease, hormone status and contact lens wear,” he said in an interview with PCON.
Dr. Morris said he would also recommend a thorough evaluation of the tear prism, meibomian glands and lid margins.
Billing for punctal occlusion
Dr. Rumpakis said when billing for punctal occlusion, practitioners should bill for the occlusion of the specific puncta only. This is code 68761, “occlusion of a punctum, by plug.” The necessary materials (the plugs) are generally incorporated into that code, he said.
“The typical sequence would be: The patient comes in for a general exam, and he or she has suspected dry eye,” he said. “You do a comprehensive exam and ask the patient to return the next week for a complete dry eye workup.”
At that time, Dr. Rumpakis said, practitioners should recommend palliative therapy in the form of an over-the-counter preparation, because most insurers require this first in the care profile. If this therapy does not work or fit the patient’s lifestyle, use a temporary collagen plug for diagnostic purposes, he said. The failure of the palliative therapy is what establishes the medical necessity for additional therapeutic steps, whether occlusion or pharmacological treatment.
“When occluding the puncta with the collagen, I would recommend using code 68761 and then a modifier for the puncta that you are doing,” he said. “The lid or punctal identifiers are upper left, E1; lower left, E2; upper right, E3; lower right, E4.”
If the patient is successful with the collagen plug, Dr. Rumpakis said he would then suggest proceeding to a permanent silicone plug, billing it the same as the collagen.
According to Dr. Dean, punctal occlusion is a surgical code that is bundled to include all related elements for a global period of 10 days.
“None of the elements should be billed separately,” he said.
Dr. Dean said most insurance policies do not suggest the number of puncta to be occluded, leaving that decision up to the practitioner.
“However, some local policies, such as New Mexico Trailblazer, dictate that they do not reimburse for more than two punctal occlusions on any given day,” he said. “If more than two are performed, it is expected that this is done only if the medical record supports the need for the additional plugs.”
Such a need would be determined based on the patient’s reported level of relief from the first two plugs, Dr. Dean said.
Dr. Morris said a few plans still allow practitioners to bill for materials (99070) in addition to occlusion (68761). “If doctors are unsure, they should file the 99070,” he said. “If they are denied, it is probably because that particular carrier has bundled the code.”
Dr. Morris said he generally starts with bilateral inferior occlusion and uses a modifier for subsequent occlusions.
“I will usually do bilateral inferior the first time,” he said. “If you do not use the -50 modifier for a bilateral procedure or the -51 modifier for an inferior and superior unilateral procedure, you will typically be denied payment.”
The global period for CPT code 68761 is 10 days, according to Dr. Dean.
“Only visits performed for unrelated problems should be billed separately during this period,” he said. “The surgical global fee is intended to reimburse the clinician for all visits related to the surgical condition during this 10-day period.”
For more information:
- D.C. Dean, OD, practices at New Mexico Eyecare in Albuquerque. He can be reached at 5600 Wyoming NE, Suite 210, Albuquerque, NM 87109; (505) 828-0828; fax: (505) 828-0848; e-mail: dcdeanod@comcast.net.
- John M. B. Rumpakis OD, MBA, is founder of Practice Resource Management in Lake Oswego, Ore. He can be reached at 5435 Southwood Dr., Lake Oswego, OR 97035-5780; (503) 968-7595; e-mail: John@PracticeResourceMgmt.com.
- Scot Morris, OD, FAAO, can be reached at Eye Consultants of Colorado, 10791 Kitty Dr., Ste. B, Conifer, CO 80433; (303) 250-0376; fax: (303) 816-7218; e-mail: smorris@eyeconsultantsofco.com.