Article Date: 8/1/2006

dry eye
Understanding the Dry Eye Annuity

Make your patients aware of the problem and show them you have the solution. It will benefit you both.

You rarely thumb through an optometric journal lately without coming across an article about dry eye. While this topic received little attention a few years ago, now it's one of the most talked-about in our profession. Let's review some of the reasons for this new prominence:

►Declining vision exam reimbursements have forced optometry to look for alternative revenue streams.

►Optometrists perform more than 67% of all eye exams in the United States, according to the American Optometric Association.

►The National Eye Institute tells us that 15% of our patients have dry eye symptoms. This number will increase as Baby Boomers reach ages where dry eye is more prevalent.

►Optometry, in most states, has therapeutic privileges that allow treatment of ocular surface disease.

Thus — optometry finally has a profitable niche.

Simply stated, there are two ways to enhance practice revenue: You can see more patients or increase the revenue you make on your existing patients. Which is easiest? Which is most profitable?

A conservative estimate of the average annual collections per dry eye patient is around $245.04. Annualized, that's about $105,855 per provider (based on the proprietary fee calculator I've developed; see the box, "Fee Calculator Assumptions," below). That would be a nice boost to your practice's bottom line. Now that I have your attention, let's talk about how you create your dry eye annuity.

Fee Calculator Assumptions

Patients seen per day: 10
contact lens wearers
Average patients per day with ocular surface disease 2.16
All collections based on Medicare

Developing a dry eye niche

Just like developing any niche in your practice, you have to concentrate on a few key things. These will take a little planning and work on your part.

Make them see the problem. The first step is to make patients realize that they have a medical problem. Face facts: Most of our patients see our profession as the place for glasses and contacts, not medical eye care. The first step is to focus on their problem. Place an ocular surface disease questionnaire in your waiting room instead of the standard out-of-date, tattered magazines. We recommend a check-box style questionnaire on one side with a brief explanation of dry eye, its causes, various treatment options and, most importantly, that your office treats this condition.

Not only does this achieve the goal of educating your patient base, it also accomplishes one of the most basic sales goals: The questionnaire is a non-confrontational way to help patients realize they need something, or in this case, that they have a problem.

Train your staff. The most important asset and investment in your practice is your staff, so use them wisely. You will only succeed at developing your dry eye niche practice if you actively involve and motivate them. Conduct a series of training sessions on dry eye. Communicate your goals to expand the scope of the practice by adding a dry eye niche and designate each of your staff members a responsibility that will move the team towards the goals. Then give them the tools to achieve these goals and an incentive program to realize them — and get out of their way.

Seven Steps to Better Patient Education

1.    Explain how you're treating (in plain English).
2.    Explain why you are treating.
   Give written instructions.
   Have patient repeat instructions.
5.    Have a family member present, if possible.
   Make them commit.
   Ask if they have questions.

Patient education. The first step in patient education is to explain that dry eye is a chronic problem and typically takes some time to get this far, so it will likely take multiple visits to manage the condition. This subtly establishes the fact that management may involve multiple medical visits over the patient's lifetime.

The second step is to be an optimistic realist. Dry eye is a manageable condition and there is a protocol to effective diagnosis and management. You have to believe that you can assist your patients. Furthermore, your staff has to see it and your patients have to believe in you in order to succeed.

The third step is to follow the basic steps to enhance your patients' compliance. (See "Seven Steps to Better Patient Education," above.)

Know your lines

Like everything else in your practice, you will need to develop a "script" for both you and your staff. These scripts should include a description of each dry eye test, a description of the different types of dry eye, as well as how they interact with each other, potential treatment options, common drug side effects and anticipated timeline for results.

Getting the word out

This is where the key rule in business comes in to play: Market, market, market! Everything you do in practice is about how you market yourself. So be proactive, market your niche aggressively and sleuth out dry eye disease in every patient who has clinical signs or symptoms. Here are a few suggestions about the marketing pieces you can employ.

►Annual newsletter: Add a section on your dry eye practice.

►Direct mail.

►Phone message: Instead of on-hold music, record a customized phone message that explains your ability to diagnose and treat many eye health issues, including dry eyes.

►In-office brochures: Ideally, make your own — or talk to your pharmaceutical representative for corporate brochures.

►Motivate your current patients to provide referrals by developing a new patient referral incentive program with movie tickets, etc., as rewards.

►Always write a follow-up education letter and/or thank you note to your patient. Not only does this provide another contact to reinforce compliance issues, but it's also a nice personal touch that shows you care.

How Do You Bill This?

Here are some billing examples for new patient

Code Typical Reimbursement
Initial Exam  


Week 6  
99214 $78.87
Week 12  
68761-E2 (ED)
Visit Total


Week 16-18  
    Visit Total   

What do you need?

The exam. The first step in any medical visit is to establish medical necessity by documenting a chief complaint. Then, as with any medical exam, you should document a thorough history, examination, patient education and a complete diagnosis and treatment plan.

Coding. All medical patients will fall into one of three categories based on patient status in your practice and the level of history taking, exam components and medical decision-making that you document.

    ■Exam codes:

    • New Patients 99201-99205   
Established Patients 99211-99215
    • Confirmatory Consults   99271-99275. These are second or third opinions when requested by the patient.

If you are not familiar with the criteria for each of the above codes, you should become so before you initiate reimbursement submission. Also be sure to use the correct procedure and supply codes when appropriate:

    ■Procedure codes: 68761 Punctal Closure by Implant

    ■"A" Supply codes. "A" codes for silicone plugs are no longer reimbursable by Medicare. Many third party insurance carriers follow Medicare's change last year   and   deny 99070 (Miscellaneous supply code) at this point. However, it is still variable, so I would suggest that you continue to bill the 99070 code. If the insurance         carrier denies the claim, you can either bill the patient, if you have him or her sign a financial responsibility waiver, or write it off.

Converting into medical

Billing Procedure Modifiers - 68761 +

E1   Upper Lid, Left
E3   Upper Lid, Right

E2   Lower Lid, Left   
   Lower Lid, Right

-25  Significant Separately Identifiable Evaluation or   Service       
Performed on the same day of the procedure
(Use with Exam, not procedure code)

   Bilateral Procedure Code

51   Additional Procedure Code

Because most people are unaware that they have dry eyes, the first step to conversion is helping the patient realize that he or she has a problem. If a patient presents a chief complaint that's medically related to dry eye, then you have the option of proceeding with the medical exam and putting the visual exam off to another time.

A more prudent method for your mild patients is to complete the vision exam and bring them back for a medical exam. The purpose is to create a second visit (and more chair time) in which you can perform more extensive ocular surface disease testing, including vital dye staining, Schirmer testing and possibly photography and microassay.

It also allows more time for patient education on the etiology and treatment strategies, as well as another opportunity to impress him or her with your expertise. The hope is that this person will become a loyal patient who in turn will help generate referrals to your practice.

Improve your bottom line

Provide a better standard of care for your patients. Provide your patients with more than just solutions to their visual needs: Take an active role in providing solutions to their eye health needs by addressing one of the most common and symptomatic problems that our patients have — dry eye. And start managing the easiest dry-eye patient you have: The one in your chair!

You'll only succeed at developing your dry eye niche practice if you actively involve and motivate your staff. Conduct training sessions and provide incentives.

Dr. Morris is the director of Eye Consultants of Colorado, LLC, and Morris Education & Consulting Associates. He is a member of the American Optometric Association and is a Fellow of the American Academy of Optometry. Contact him at

Optometric Management, Issue: August 2006