BUSINESS: Coding Strategy

Evaluate DED Protocols

Questionnaires provide subjective documentation of the disease

With this being Optometric Management’s annual dry eye disease (DED) issue, take this opportunity to analyze your protocol for diagnosis, treatment and care. A helpful aid: the Dry Eye LCD titled: “Diagnostic Evaluation and Medical Management of Moderate-Severe Dry Eye Disease (DED),” available on Medicare’s website ( ).

One of the first things to look at is what tools you are using in your practice; specifically, the questions you ask to consistently assess patient symptoms, both in your initial exam and upon follow-up. By having subjective documentation from your patients regarding their symptoms, added to their medical records, you have the required medical necessity to perform further diagnostic testing, to initiate treatment, to schedule further evaluations to determine effectiveness of the treatment and receive reimbursement for your skill set. Below is the section related to dry eye questionnaires from the Dry Eye Disease LCD. (For the complete document, please go to the web address above.)

There are several dry eye questionnaires that assess patient symptoms. Many have been statistically validated as effective instruments to screen for dry eyes. The Ocular Surface Disease Index (OSDI), the Standard Patient Evaluation of Eye Dryness (SPEED) and the 5-Item Dry Eye Questionnaire (DEQ-5) questionnaires are valid and reliable instruments for measuring the severity of dry eye disease. The OSDI analyzes patient responses across three different subscales: vision-related function, ocular symptoms, and environmental triggers. The OSDI has good to excellent reliability, validity, sensitivity, and specificity for the overall questionnaire and each subscale. The OSDI is effective in discriminating between normal, mild to moderate, and severe DED as defined by both physician’s assessment and a composite disease severity score. The DEQ-5, the sum of scores for frequency and intensity of dryness late in the day and discomfort plus frequency of watery eyes, effectively discriminated across self-assessed severity ratings and between patients with dry eye diagnoses. The SPEED questionnaire was shown to be a repeatable and valid instrument for measurement of dry eye symptoms. The SPEED score also correlated significantly with ocular surface staining and clinical measures of meibomian gland function. Along with other clinical and subjective measures of DED, these questionnaires provide a quantifiable assessment of dry eye symptom frequency and the impact of these symptoms on vision-related functioning.


The questionnaires can be found on several different websites. They are open source and can be downloaded and customized with more questions when you feel appropriate. For example, “Are your eyelids ever red or inflamed?” Web-based applications can also be found that allow a patient to complete the questionnaire on a digital device before coming in to the optometrist’s office, if so desired.


Dry eye questionnaires are not required by Medicare at this time, and there is no reimbursement for having a patient complete one. The benefit of a subjective questionnaire is that it adds validity to the continuation of care for the patient. I would recommend you choose the one most relevant to you, customize it with your brand (i.e. practice name), and include it in the patient’s record. As with any diagnostic tool, much of the value is in how we communicate the results with the patient and utilize it to increase patient compliance with treatment and further care. OM