The Dry Eye Workshop (DEWS) II study defines dry eye disease (DED) as “…a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which the tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”1
Dry eye disease: Prevalence and profit
The two major forms of DED are evaporative, usually caused by meibomian gland disease (MGD), and aqueous deficient dry eye, which may be caused by such factors as aging, connective tissue diseases, thyroid disease, and medication side effects. Demodex blepharitis can also significantly affect DED. The increased use of digital devices by all age groups is also a major factor that makes patients more symptomatic of their DED and causes them to seek care.
As we learn more about the causes and various treatments for DED, and how it affects the daily lives of patients, more eyecare practitioners are incorporating treatment of DED into their practices. Considering that 5 to 15% of the US population has DED,2 and the chronic nature of DED, incorporating a dry eye clinic into a practice offers a much-needed service for the patients and can significantly increase practice income.
It is estimated that the costs of DED per patient can be as much as $11,302 per patient over time and as much as $55 billion per year in the United States.3 The care of these patients qualifies as medical eyecare, which allows for many of the visits and some of the treatments used for DED to be covered by major medical plans, including Medicare.
The biggest mistake made in treating DED is by providers who treat DED patients and file for their services with vision plans, instead of medical insurance, and are potentially losing thousands of dollars per year in income. Some of the treatments for DED, such as intense pulsed light (IPL), microblepharoexfoliation, and thermal evacuation, are not covered by medical plans, which allows providers to collect full fees for patient treatment.
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Common Dry Eye Codes
Use this cheat sheet with dry eye CPT and ICD-10 codes to optimize the coding and billing process and increase your practice's profits.
Dry eye billing and coding considerations
Caring for DED qualifies as medical eyecare and not “routine” eyecare. Therefore, it is important that providers understand how to properly bill for patient exams, testing, and some treatment procedures that are covered by medical insurance. Fees for non-covered tests and treatments should be collected from the patient on the date of service.
If a patient insists that the provider bill an insurer for non-covered services, and there is an appropriate CPT code, the patient should sign an advance beneficiary notice (ABN) or other similar form acknowledging personal responsibility for those fees when the insurer denies payment for those services.
Using correct E/M codes
When billing for patient office visits, providers should utilize the 99xxx E/M codes because, unfortunately, several major medical plans have improperly classified the 92xxx ophthalmology/optometry codes as applying only to “routine” non-medical eyecare services. Technically, according to the CPT definitions for both the 92 and 99 codes, providers should be able to use either code set for medical visits.
However, due to the improper reclassification of the 92 codes by many insurers for use for “routine” care only, many providers are finding claims with the 92 codes are being denied payment. Also, in most cases, the 99 E/M codes will pay at a slightly higher fee than the 92 codes. In general, when doing an initial examination for a patient with DED, or a patient who is currently being treated and is experiencing complications, a 992x4 E/M code would be appropriate.
When seeing patients for periodic progress exams, who are improving or stable as a result of their treatment, a 99213 exam code would be appropriate, even when refills for current DED medications are ordered. There may be exceptions to these recommendations.
Don't forget to download the cheat sheet with common dry eye codes!
Specificity is key for dry eye coding and billing
When choosing the ICD-10 diagnosis codes for patients, it is critical to use the codes with the highest specificity and not use “unspecified” diagnosis codes because that may lead to claims being denied payment.
When billing for tests and procedures that are covered by insurers, it is important to use the appropriate modifiers with the test/procedure CPT codes and to link them to approved ICD-10 diagnosis codes. The best way to check for approved diagnosis codes is to do an on line search for the LCD (local coverage determination) for the procedure.
While an LCD is specific to Medicare, most major medical plans will utilize those coding guidelines for reimbursements. The LCD will also often include information about proper documentation, test/procedure approved frequency, and global periods for procedures such as punctal plugs.
Since most payors also have their own lists of approved CPT and ICD-10 codes for procedures, providers should also obtain those lists either on the payor website or from the provider relations offices
Procuring prior authorization
Also, some insurers are now requiring pre-authorizations for such procedures as amniotic membranes (65778) and utilizing scleral contacts (92313, bilateral code). If providers do not obtain the appropriate pre-authorizations, their claims could be denied, and they may have a difficult time collecting appropriate fees directly from patients. Each payor may have its own process for obtaining pre-authorizations for services.
Therefore, the billing staff should contact payors to learn their specific process. Some payors utilize outside services to handle pre-authorizations for medications and other services. Providers should also determine their level of reimbursement from insurers to ensure that they will properly reimburse them for their exams and materials (V2531 - scleral gas permeable contact lens, RT or LT) provided.
Punctal plugs
Another common dry eye treatment procedure is punctal plugs (68761, with modifiers for the eye(s) involved [RT, LT, 50] and for the lid(s) whose puncta have been treated [E 1-4]). The reimbursement includes both the procedure and the punctal plug materials.
In general, the procedure may be repeated every 6 months. However, some insurers will reimburse for quarterly procedures.
Key takeaways on dry eye coding and billing:
- DED care should only be billed to medical insurance.
- Non-covered DED visits and treatments should be paid for out-of-pocket by patients.
- Providers need to stay up to date with the latest research and treatments for DED.
- Appropriate CPT and ICD-10 codes, along with proper modifiers, should be used for billing to insurers.
In closing
With the prevalence of dry eye increasing, those providers who embrace testing and treatment, beyond just handing the patients a sample of artificial tears, will benefit from both the professional and financial rewards involved with the treatment of DED and provide an important service to their patients.
