Medicare documents provide a step-by-step guide for DED-covered services

Dry eye disease (DED) coding requirements for Medicare, and, therefore, most insurance companies, continue to evolve. Updates often take place as new technologies are approved by the FDA, and new research and data reveal appropriate paths to better outcomes. As the protocols evolve, it’s important to review them regularly to remain compliant.

As a reminder, every state has its own Medicare carrier (some states share a carrier) and, hence, may follow slightly different guidelines. However, they generally stay the same. (Look at your state guidelines for your specific path to follow.) For the purposes of this column, I direct you to First Coast, as it is my Medicare carrier in Florida. Your resource for my statements in this column is bit.ly/LCDdryeye . I recommend you print the LCD and follow along. Each section subhead references a corresponding heading in the LCD.

“TERMINOLOGY AND GUIDELINES”

When reading through this proposed (as of press time) LCD, it is wise to use the “Terminology and Guidelines” to direct your protocol. If one knows they will be evaluated (in an audit) to determine the path they took regarding these areas, it is wise to create a protocol that guides you down that specific path.

“COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY BACKGROUND”

In this section, DED is defined. Consider utilizing this definition to categorize these patients. The LCD then goes on to outline the signs of DED. Create the questions in your protocol that will check the box of which of these signs your patient is experiencing. Associated disorders, which also should be captured in the medical record, are discussed, and then symptoms are specifically mentioned, including reduced VA.

“DIAGNOSTIC TESTING”

The initial exam requirements are detailed here as well as commonly used objective tests that could (which means should) be used as well. This section also describes tests that would not be described as medically necessary for DED patients.

“MANAGEMENT”

This section begins the discussion of treatment for DED. Resources are given for creating your own treatment algorithm. (Of note, punctal occlusion is described in detail, which is a good clue to be certain to follow the rules closely when considering this option.)

“LIMITATIONS”

This section reviews which options are not medically necessary, which means they will not be covered by Medicare.

“DOCUMENTATION REQUIREMENTS”

This is my favorite section because it specifically describes what must be documented in the chart for examination and treatment of our DED patients for Medicare to pay for the visit and for the provider to not be at risk for recoupment of reimbursement after an audit. Remember, no one ever loses in an audit because of too much documentation.

“UTILIZATION GUIDELINES”

This section helps providers to know how often they are going to be able to see these patients and how often they will be covered to do certain procedures in the office. The document mentions “standards of practice,” which may seem vague and, yet, the LCD provides the source immediately following this section for where to find these “Standards of Practice.”

BEST CLINICAL JUDGMENT

Several times in this LCD, reference is made to the fact that doctors should use their best clinical judgment. However, it is always wise to look at the sources used for creating this LCD, and keep those on file to defend what one considers their best clinical judgement in case it is ever questioned later in an audit.

Always remember that, as times change, the rules will change. Keep up-to-date with the new rules, but keep a copy of the old ones on file so that, in the case of an audit, you have the rules that correspond to the time period for which you are being audited. OM

DR. JASPER practices in West Palm Beach, Fla.. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.