Article Date: 8/1/2009

Correctly Bill And Code For Dry Eye
dry eye

Correctly Bill And Code For Dry Eye

Get the reimbursement you're entitled to by familiarizing yourself with the following.

PAUL KARPECKI, O.D., F.A.A.O., LEXINGTON, KY, AND JOHN LAHR, O.D., F.A.A.O., Cincinnati, Ohio

About 30% of the patients you see every day should be treated for dry eye, according to a 2005 Gallup Survey. As a result, it's important you know how to bill their visit, so the patient receives the best treatment, and you don't lose out on the appropriate reimbursement. (See "Resources Required For Managing Dry Eye," below.)

Choosing the plan

Many primary eyecare practices face the dilemma of whether to bill the medical plan or the vision plan for the initial visit. If the patient is eligible for the preventive eye exam under either plan, this is always an available service to perform and bill.

If you suspect ocular surface disease once you've completed the exam, schedule the patient for a work-up for the condition, and inform him you'll bill the work-up to his medical insurance.

The key component for billing a patient's medical insurance on the initial presentation is the patient's chief complaint. This is a problem when dealing with many dry eye patients, as the condition is often an underlying issue, and, therefore, something we find after performing a comprehensive eye exam and a subsequent ocular surface disease work-up. For this reason, it's important for medical billing that you find a link between the chief complaint and the ocular surface disease.

The other overriding factor in determining the plan to which to submit the claim is the patient's expectation upon entering your practice. If he presents his vision plan card or verbally proclaims that his vision plan will cover his initial visit, accept the patient's assertion, and bill the vision plan for the initial visit. Then, reschedule the patient for a dry eye work up, which is billed to his medical plan.

Billing codes

A first exam with a patient who complains of mild to moderate dry eye symptoms is most commonly a comprehensive ophthalmological service, with the billing code 92004 and if you've performed a refraction, code 92015. This comprehensive exam, including dilated retinal evaluation, helps you identify underlying problems and uncovers systemic diseases associated with dry eye, such as diabetes.

When a patient complains of blurred or inconsistent vision or burning, itching or gritty sensations, revisit his medical history. Why? Past ocular surgeries and oral or topical medications can greatly worsen dry eye.

Should a patient present with obvious dry eye signs and symptoms, making a quality refractive outcome unlikely, educate him that his ocular surface inflammation is the primary cause of his problems, so you'll bill the visit to his medical carrier. (See "Most Common Dry Eye Diagnosis Codes And Modifiers," below.)

Claim submittal

Once you've established the foundation for ocular surface disease and have developed your treatment plan, submit the claim(s) for the services, testing and treatment.

The majority of your billing for ocular surface disease will be office service codes (99201-99205 and 99212-99215) along with ancillary testing, such as external photography (92285) and treatment services, which include punctal occlusion (68761).

Begin mild to moderate dry eye treatment using advanced technology artificial tears. Where inflammatory response is suspected, prescribe a steroid and cyclosporine ophthalmic emulsion 0.05% (Restasis,Allergan). Long-term management includes Omega 3 (fish oil) in the range of 2.0g to 4.0g of EPA/DHA supplements per day with options of cyclosporine, artificial tears and punctal occlusion. (See "Ocular Procedures in Dry Eye," below.)

Knowing the proper guidelines for including disease states in a patient's medical record is also important to obtain the appropriate reimbursement. As with every clinical record, the patient's medical record should include the date of service/treatment, along with you, the service provider's name.

For each visit, include a reason for the appointment (chief complaint), relevant medical history, prior diagnostic test results, your clinical impression or diagnosis and the treatment plan. The patient's medical record should also include the rationale for your chosen plan for care, any expected reactions and any potential adverse effects associated with this treatment and the reason and timing of the next visit. Be sure your chosen treatment and your assessment of the patient's dry eye address the chief complaint. In order for you to get reimbursed for your services, all this information must legible and support the CPT and ICD-9-CM codes reported on the health insurance claim.

Due to advances in diagnostic devices and treatments, a lot of opportunity exists to help patients who have ocular surface disease problems, while also increasing the financial success of your practice. Many of us, however, don't take a systematic, protocol approach in treating the full range of ocular surface diseases. By properly evaluating the ocular surface and developing a treatment plan and accurate clinical records, you give yourself the opportunity for full reimbursement for your services and treatment. OM

Dr. Karpecki works in corneal/external disease and in ocular surface disease research at the Koffler Vision Group in Lexington, Ky. E-mail him at paul@karpecki.com.
Dr. Lahr currently serves as the vice president of Provider Relations and medical director for EyeMed Vision Care in Mason, Ohio. Also, he served on the American Optometric Association's (AOA) Eye Care Benefits Executive Committee for 10 years and as the AOA's first representative to the American Medical Association's CPT coding committee. E-mail him at jwlahr@earthlink.net.


Optometric Management, Issue: August 2009