Managing clinically significant dry eye is all the rage in today’s optometric practice—and with good reason. For one, surgeons need a pristine ocular surface prior to performing any refractive surgical procedure for the best outcomes. As providers on the frontline, ODs must capture this population presenting to their practices on a daily basis, whether it’s obvious clinically significant dry eye, a contact lens dropout or that troublesome patient who complains that their eyes just don’t feel as comfortable as they used to throughout the day. Once you capture the patient, here’s how to capture the reimbursement for their care.
Dry eye management now boasts specialized equipment, tests and treatments, as well as various protocols. All of these come with differing economic returns for the practice. But many wonder if you really need all of this specialized equipment. Likewise, do you need to perform all of these tests for every patient to be considered a good practitioner? The answer is no, not really.
First Things First
More often than not, the clinical record does not support much of this testing and, in many cases, there is an absence of clinically specific tests that should be done if recommending certain therapies. Let’s take a step-wise approach to this:
Step One: The Complaint. First, we must have a chief complaint related to the ocular surface. This can be a direct patient statement or a clinical finding discovered during a patient’s regularly scheduled comprehensive examination.
Step Two: Testing. After properly documenting the complaint in the patient’s medical record, you can start building the case of medical necessity for each clinical test you need to perform based on the specific patient. Clinical signs you might document include hyperemia, edema, meibomian gland dysfunction, inflammation, corneal staining and lid margin epitheliopathy, to name few. These signs warrant appropriate clinical testing.
For example, if you suspect an inflammatory component or need to rule it out, order a specific clinical test for inflammatory markers such as Quidel’s InflammaDry (CPT 83516 – QW). The outcome of this test may also assist with getting a prior authorization for a specific medication, but the result must be in the medical record. Remember, to bill for any CLIA-waived clinical lab point-of-care tests, your office must be designated as a clinical lab and one physician must be designated as clinical lab director.
Other clinical tests such as meibography, previously coded as an anterior segment photograph (CPT – 92285), must meet the standard of medical necessity before you can order and perform them. If the clinical record shows the presence of obstructed orifices, you can perform meibography, but only if it is based on the clinical findings. As of January of this year, the code for meibography changed to a Category III code, 0507T, defined as: “Near-infrared dual imaging (i.e., simultaneous reflective and trans-illuminated light) of meibomian glands, unilateral or bilateral, with interpretation and report.”
Most carriers now designate this as a patient pay code.
Step Three: Treatment. When treatment is indicated, be sure to follow the rules. For example, if you need to debride the lid margin or express the meibomian glands, neither have a specific CPT code to describe them. If you follow the CPT rules, the coding is easy. Because no CPT code currently exists for meibomian gland expression done in a non-surgical fashion, you have to use CPT code 92499 – Unlisted Ophthalmic Procedure to bill for it separately and distinctly. However, carriers generally do not reimburse for 92499, and coding with it simply allows the patient to pay you directly for it. If you choose to submit 92499 to the carrier, properly complete an ABN form, and collect from the patient in advance as directed in Option #1 of the ABN.
Clinical care protocols are wonderful if you use them properly. These tools can help you diagnose and manage the condition, but never feel compelled to do every test, every time, on every dry eye patient. That is not the purpose of a protocol, nor is it defendable in a carrier audit. Rather, use the tools with discretion to provide great care.
Send your own coding questions and comments to firstname.lastname@example.org.