Dry eye syndrome is one of the most prevalent ocular diseases in this country. Often, signs and symptoms of dry eye syndrome are discovered during a comprehensive examination rather than when a patient comes in with a specific complaint. When further testing is indicated, it may be best done as a follow-up evaluation to avoid the impact of standard ocular examination techniques on the ocular surface.

The evaluation for dry eye syndrome typically involves several examination techniques and ancillary tests. These tests do not have separate procedure codes:

Patient history (dry eye surveys, symptoms, circumstances, etc.).

Tear break-up time (TBUT).

Schirmer testing (I and II).

Cotton thread or phenol red thread testing.

Sodium fluorescein, lissamine green and/or rose bengal staining.

Tear prism evaluation.


Once youve diagnosed a patient with dry eye syndrome and formalized a treatment plan, youll typically require several subsequent visits to evaluate the effectiveness of the plan and alter it as necessary. These follow-up visits are typically billed using 99212, 99213 or 92012. Coding at higher levels rarely meets the medical necessity requirements of those codes.

If you decide that the patient might benefit from punctal occlusion, the billing is the same for temporary diagnostic plugs and permanent plugs. The design of the permanent punctal plug you use does not impact the billing code. The supply of the punctal plugs is typically included in the insertion code. This procedure is billed per plug as follows:

One plug: 68761.

Two plugs, different eyes: 68761-50 (billed at 200% of one plug).

Two plugs, same eye: 68761-51 (billed at 200% of one plug).

Three plugs: 68761-50 (billed at 200% of one plug) and 68761-51 (billed at 100% of one plug).

Four plugs: 68761-50 (billed at 200% of one plug) and 68761-50-51 (billed at 200% of one plug).

The multiple surgery rule applies, so the payment is typically 100% for the first plug, 50% for the second plug, and 25% for each of the third and fourth plug. Carriers often require a statement of medical necessity from the physician if occluding more than two puncta on the same day of service.

Most of the time, adding the -E modifier to the surgical code designates which punctum is being occluded. Each plug may be billed on a separate line at 100% using the appropriate -E modifier (and, as in the examples above, payment follows the multiple surgery rule): E1, upper left; E2, lower left; E3, upper right; E4, lower right.

The postoperative period for punctal occlusion is 10 days. If a patient returns within that time period for a follow-up visit related to the punctal occlusion, that visit is included in the original billing procedure. However, if a patient returns for an unrelated problem, bill that visit using the -24 modifier (unrelated evaluation and management during the postoperative period) appended to the office visit code.

When considering therapy, bear in mind that many drug coverage plans require the keratitis sicca diagnosis code before covering certain prescription therapies. (Also, many carriers require the use of palliative over-the-counter artificial tears prior to any prescription therapy.) The appropriate diagnosis code options are dry eye syndrome (375.15) or keratitis sicca (370.33). Sjgrens syndromekeratoconjunctivitis sicca (710.2) is also a possibility, but be familiar with each carriers specific requirements prior to initiating any therapy.

Optometrists should be familiar with current methods of diagnosis and treatment as well as appropriate coding to ensure that the patient receives the standard of care for this very common condition and that the practice is in compliance with standard billing procedures. This combination makes for a happy patient and a profitable practice.


 Clinical Coding Committee

John Rumpakis, O.D., M.B.A., Clinical Coding Editor

David Mills, O.D., M.B.A.

Laurie Sorrenson, O.D.
Rebecca Wartman, O.D.
Joe DeLoach, O.D.

Vol. No: 146:02Issue: 2/15/2009