Signs and symptoms of dry eye syndrome are often discovered during a comprehensive exam. When further testing is indicated, this may be best done as a follow-up evaluation. This evaluation for dry eye syndrome most likely involves several examination techniques and ancillary tests. These tests, which do not have separate procedure codes, include:

• Patient history (dry eye surveys, symptoms, circumstances, etc.)
• Tear film break-up time (TFBUT)
• Schirmer testing (I&II)
• Cotton thread or phenol red thread testing
• Sodium fluorescein, lissamine green and/or rose bengal staining
• Tear prism evaluation
• Evaluation of lid wiper epitheliopathy
• Biomicroscopy and examination of ocular surface and lid margins

These tests help you formulate the diagnosis. The appropriate diagnosis code is usually dry eye syndrome (375.15) or keratitis sicca (370.33). Sjögren’s syndrome/keratoconjunctivitis sicca (710.2) is also a possibility, although you should be familiar with your carrier’s requirements prior to initiating any therapy.

In general, before contemplating either surgical or prescriptive treatment, you should have a well documented record of palliative therapy with an artificial tear protocol. The failure of the artificial tear treatment is what provides the medical necessity to proceed to more invasive treatment.

Once you’ve made the diagnosis of dry eye and formalized a treatment plan, several subsequent visits are typically necessary to evaluate the treatment plan. Both the diagnostic and treatment visits are billed using the appropriate office visit codes only. Keep in mind that if you perform the diagnostic examination on the same date as the comprehensive exam, it is not billable as a separate/distinct visit in addition to the comprehensive examination. Follow-up visits to assess the effectiveness of treatment, to alter or to add to the treatment plan are billed using 99212, 99213 or 92012.

If you decide the patient requires punctal plugs, the billing is the same for temporary diagnostic plugs and permanent plugs. The supply of the punctal plugs is typically included in the insertion code. The insertion procedure is billed per plug in one of two ways. Here is the first method:

• One plug: 68761
• Two plugs, different eyes: 68761-50 (billed at 200% of one plug)
• Two plugs, same eye: 68761-51 (billed at 200% of one plug)
• Three plugs: 68761-50 (billed at 200% of one plug) and 68761-51 (billed at 100% of one plug)
• Four plugs: 68761-50 (billed at 200% of one plug) and 68761-50-51 (billed at 200% of one plug)

The “multiple surgery rule” applies, so the payment is typically 100% for first plug, 50% for the second plug, and 25% for each of the third and fourth plug. The -50 modifier indicates a bilateral procedure on the same eye and the -51 modifier indicates multiple procedures on the same eye. See Appendix A in your CPT book for further details.

The second method for billing punctal occlusion is adding the E modifiers to the surgical code to designate which puncta are being occluded. Bill for each plug on a separate line using the appropriate E modifier:

• E1: upper left
• E2: lower left
• E3: upper right
• E4: lower right

The global period for punctal occlusion is 10 days. So, if a patient returns within that period for a follow-up visit related to the punctal occlusion, then that visit is included in the insertion fee. However, if a patient returns for an unrelated problem, then that office visit must be billed using a -24 modifier (unrelated evaluation and management during a postoperative period) in order for you to be compensated for that encounter.

Please send your comments to