It is estimated that dry eye disease affects 5 to 20% of the population in Western countries and 45 to 70% in Asian countries—this translates to approximately 20 million people in the United States and 344 million people worldwide who have been diagnosed with DED.1,2,3
Add in the undiagnosed in the US, and the number jumps to 30 million.2 In the Eyes On Eyecare 2024 Dry Eye Report, our respondents (most of whom are in private practice) estimated that well over half of their patient population—67.55%—had some form of DED.4
These statistics were echoed by Dr. Dierker: “When we look at the stats, the most common medical condition presenting to an optometrist is going to be something in ocular surface disease, whether it's dry eye, meibomian gland dysfunction, or blepharitis.” Considering this, he feels every practice should offer some level of dry eye service based on evidence-based medicine and utilize key performance indicators (KPIs) to track.
Dr. Wolfe added, “If you present from the podium and ask, ‘What's the prevalence of meibomian gland dysfunction (MGD) in your patient population,’ everybody will tell you the minimum is 50%, but most people will report some dysfunction in 100% of their patient population.”
Establishing dry eye disease
The majority of patients who walk through the door of Dr. Wolfe’s practice, Exclusively Eyecare in Omaha, Nebraska, have comprehensive needs, meaning they present with both acute and chronic conditions that need to be fully addressed. Therefore, he does not consider himself a specialty clinic but instead a comprehensive clinic.
However, every patient receives a basic dry eye evaluation during their comprehensive exam and is scheduled for a follow-up if the signs or symptoms point to DED. During the comprehensive exam, both ODs utilize four questions established during the 2014 Dry Eye Summit with the goal of easy-to-implement consensus recommendations for the diagnosis and management of DED in clinical practice.5
According to Dr. Wolfe, “To uncover potential problems or existing problems or future problems, it is imperative to ask the right questions.” These questions should be asked of each patient at every visit.
They include:
- Do your eyes ever feel dry or uncomfortable?
- Are you bothered by changes in your vision throughout the day?
- Are you ever bothered by red eyes?
- Do you ever use or feel the need to use drops?
Discussing dry eye disease with patients
During the comprehensive exam, Dr. Wolfe advises keeping the DED questions to “yes” and “no” answers and keeping the focus on the chief complaint. If DED is detected or suspected, he schedules a follow-up appointment to delve deeper.
Below is a sample conversation to encourage the patient to follow up:
"Great news; I've got a new prescription for you to address your chief complaint. But I'm also noticing you have some oil glands that are backed up, and that's causing your eyes to get red occasionally throughout the day. So, I want you to start doing warm compresses and lid scrubs [and potentially an artificial tear if the clinician believes that is important]. I want to see you in a month to take a deeper evaluation."
On the DED-focused, follow-up visit, Dr. Wolfe utilizes the SPEED questionnaire and point-of-care testing to gain a more thorough understanding of the individual’s condition.
Discrepancies in the day-to-day vs. data
As the founder of Eyecode Education, a company specializing in clinical and billing education to help eyecare professionals integrate and properly code for this full range of services, Dr. Wolfe pays special attention to billing and coding habits and the metrics that practices use to analyze. In looking at these numbers, he realized optometrists are missing opportunities to capture the services they are providing in regard to DED.
He points out that many practices use various forms of testing, such as meibography, osmolarity, lactoferrin, and matrix metalloproteinase-9 (MMP-9), but this is not reflected in their billing. However, when you examine Medicare data and analyze individual practices to see indicators of what these practices are actually billing for, dry eye diagnostics and treatment are grossly underrepresented.
“That's an issue; it means we purchase equipment, and we don't know how to get paid for it,” Dr. Wolfe stated. In his analysis, Dr. Wolfe also found that it is not uncommon for a practice to bill for 1,000 refractions but only 10 anterior segment photos, which is exceedingly low when you consider the following.
If a practice sees 1,000 patients for a comprehensive exam and refraction, statistics tell us that 70% of those, especially if these individuals are over the age of 40, will have some level of MGD. If this is true, billing should reflect some variety of testing on up to 700 patients.
For a deep dive into what optometrists need to know about coding and billing, check out The Ultimate Guide to Optometry Billing and Coding!
The most common mistake in dry eye coding
In Dr. Wolfe’s opinion, the most common coding and billing mistake optometrists make is undervaluing their services. He points out that AMA guidelines for 99 codes include problems, symptoms, signs, and findings. Dr. Wolfe finds optometrists are often guilty of billing based on how they felt about the difficulty level of the interaction, not how it was actually coded.
Dr. Dierker pointed out, “Probably 80% of my clinic visits end up as a level 4 encounter. That's following the rules that are given to us.” With most dry eye patients, there are at least two chronic conditions, be it DED and MGD or DED and superficial punctate keratitis (SPK), so multiple chronic problems are being addressed.
During the encounter, determine whether the appointment qualifies as level 3 or level 4:
- Level 3: The patient has two chronic conditions, and over-the-counter medication is recommended.
- Level 4: The patient has two chronic conditions, and additional prescription medication or a procedure that carries additional risk factors is ordered.
Looking to the future: Trends in dry eye coding and billing
Data drives 99 codes, yet most of the tests optometrists perform in their practice, including optical coherence tomography (OCT), visual field, fundus photography, and anterior segment photos, cannot be included as data because doctors are already being paid to do an interpretation and report.
For Dr. Wolfe, the most exciting upcoming change is in the classification of point-of-care testing. As more point-of-care tests like osmolarity and MMP-9—which allow us to be more accurate in our diagnosis and can be considered as data since there is no payment for interpretation and report—become approved, we may see data driving more of the coding in ways it was only minimally applicable in the past.
That means that simply doing all three tests on a patient, whether or not accompanied by a prescribed medication or a procedure, will qualify the encounter as a level 4. “If we can have a battery of tests that help us to make a better diagnosis, pick a better treatment plan, and are able to be compensated for those services, I think that's a win all around,” Dr. Dierker stated in closing.
