Article Date: 6/1/2008

Building a Lucrative Dry Eye Subspecialty

Building a Lucrative Dry Eye Subspecialty

Use these strategies to develop a dry eye patient base that can increase practice revenue.

By Douglas K. Devries, O.D., Sparks, Nev.

COMMON OCULAR HEALTH issues like ocular allergy, cataract and glaucoma generate many office visits for diagnosis and follow-up. However, we can add dry eye to the list, too, because The National Eye Institute estimates that 15% of Americans have dry eye symptoms, and the rate is even higher among older patients.

But here's the irony: Optometrists perform more than 70% of eye exams in the United States, yet medical offices prescribe 65% to 75% of prescriptions for dry eye medications. The good news is that O.D.s can turn this missed opportunity into a profitable therapeutic subspecialty. We can give patients more treatment options and better care, while adding extra income to our practices.

As a new O.D., you can manage dry eye patients with no new equipment—just a small investment in materials like dyes and test strips. The key is to implement this subspecialty systematically with a clear treatment schedule that organizes the best possible care into a medical reappointment model.

Managing Through Reappointment

In optometry, we have a tendency to do too much in a single visit. In the medical model, doctors discover an issue during a routine exam, and then make a second appointment to run additional tests. This model enhances patient care, keeps your practice running more efficiently and increases profits.

Patients receive better care because you're delving more deeply to determine the cause of their condition during the follow-up visit. The patient history, questionnaire and routine exam will give you a good foundation. If a patient reports dry eye problems and my exam confirms the condition, I talk to the patient. I acknowledge the symptoms, appearance of the eye and exam results, and recommend a second appointment.

Coding for Dry Eye
Billing for chronic dry eye disease isn't too complicated. Visits may require different codes, based on the complexity of the patient's problem and your testing and treatment protocols.

The choices usually are:
  • Level II evaluation and management code 99212
  • Level III evaluation and management code 99213
  • Intermediate ophthalmic exam code 92013

This is where I save significant time. By recommending a second appointment, I'm ending the dry eye portion of the routine exam. I don't spend additional time on testing, education, treatment and management. The patient is left to consider how much of a problem dry eye is in her life. If dry eye isn't a major issue, the patient won't make another appointment, and I'll be glad that I didn't spend time dealing with a problem that doesn't really bother her. If the dry eye is bothersome enough for the patient to make another appointment, then I have the opportunity to treat the patient, while also increasing revenue.

Adding Revenue

Let's consider the numbers. If 15% of people have dry eye symptoms, a smaller percentage, say 5%, will make another appointment. If you see 60 patients a week, that's 3 patients per week making additional appointments. These patients will require the initial evaluation and treatment, a follow-up appointment and additional follow-up as needed. My patients typically have three to five visits, but some have as many as eight. In addition to office visits, nearly half of my dry eye patients receive punctal occlusion.

On average, dry eye patients generate just under $500 in revenue per year. Assuming you see three of these patients per week, you're looking at a possible $78,000 per year in new revenue.

Evaluation and Treatment

But diagnosis, treatment and management of dry eye don't just benefit your practice. They benefit patients as well. Patients don't want to live with a condition that causes discomfort on a daily basis. They expect an effective treatment that provides sustained relief. When you recommend a second appointment for dry eye patients, it enhances your image as the professional who can address their comprehensive eye health.

From the start, it's important to document patients' symptoms, eye appearance, exam and test results. The documentation sets a baseline for treatment and supports your billing.

Begin the dry eye evaluation process by having patients fill out a questionnaire that allows them to rate their dry eye symptoms. Many times, patients suffering with dry eye don't even realize they have a problem until they think about these questions. My patients complete this questionnaire after their other paperwork is done, and we review their answers together.

Of course, during the regular exam, I do a slit lamp examination, look at the tear meniscus and check for general inflammation of the eyelid. At the return visit, I evaluate the quality and quantity of tears. I measure the tear meniscus with a small circular beam, test the tear film breakup time with a fluorescein strip, do a lissamine green test for conjunctival and corneal staining, express the meibomian glands and perform a Schirmer's or phenol red thread test.

Treatment typically begins with oral and topical therapies and a daily hygiene regimen. If the patient has lid disease, I address that first. Patients return after about 6 weeks of treatment, and I perform the same tests to assess their improvement. The patient might be better, or we might change treatments or insert punctal plugs. For any modifications, we make a follow-up appointment 6 to 8 weeks later.

Remember to educate patients at the first follow-up appointment when you make the diagnosis and prescribe treatment. When they understand that dry eye is a chronic, treatable condition, they begin to view their symptoms in medical terms, instead of thinking of them as a common nuisance. They also begin to understand and appreciate the quality of care your practice offers.

Profits for Any Practice

The dry eye subspecialty offers a tremendous opportunity to help build a new practice. It's also a major selling point if you're working in an established practice. The staff can issue patients a questionnaire and make follow-up appointments for patients to see the new "dry eye" associate. Patients receive more comprehensive treatment without placing any additional burden on the existing doctors. In return, your time slots become filled with referrals, and you get an introduction to this additional, lucrative patient base. nOD

Dr. Devries is cofounder of Eye Care Associates of Nevada, a medical/surgical comanagement referral practice. You can reach him at

Optometric Management, Issue: June 2008