As this month’s article “Dealing with DES: In the Present and in the Offing” discusses, dry eye is benefiting from classic and nouveau treatment approaches. Many patients see results with basic treatments; but, if more advanced techniques are required, it is essential to maintain a proper sequence of events in the medical record to establish medical necessity. While specific diagnoses and treatments require specific coding instruction, the vast majority of treatment for ocular surface disease (OSD) is based on the office visit.
The Office Visit
Whether you use the 920X2 intermediate ophthalmic code or a 99201 – 99214 E/M code, remember that medical necessity applies to coding the office visit as well. The Centers For Medicare and Medicaid Services (CMS) are very specific about medical necessity of an office visit, as stated in CMS IOS Publication 100-04, Chapter 12, Section 30.6.1:
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
Punctal Plug Coding
Three punctal plugs
Four punctal plugs
There is no difference in coding whether you are using collagen, silicone or hydrogel material to occlude the puncta. CPT 68761 carries a 10-day global period.
Properly perform only the necessary elements of the exam and document them correctly, which will establish the proper office visit code.
Treatment protocols such as artificial tears and ointments, secretagogues, topical anti-inflammatory therapy, Restasis (cyclosporine, Allergan) and nutritional supplements generally don’t require any procedure-specific coding and are billed as office visits. OSD is chronic, multifactorial and very commonly requires multiple visits per year; yet, many practitioners do not recognize the value of proper coding and follow-up to manage and track dry eye therapies. This could easily be worth $200 to $350 per year per patient. With conservative numbers showing a natural incidence and prevalence rate of about 25% of the US population, the economics of providing proper dry eye care are quite attractive.1
Minor Surgical Procedures
Here are a few minor procedures common in ophthalmic practices and how to code them:
• Punctal occlusion. Standard rules for coding a minor surgical procedure apply. Any surgical procedure with a global period less than 90 days is considered a minor surgical procedure, and, by definition, the surgical code already contains compensation for an office visit on the day of or the day preceding the procedure in addition to the surgical procedure. Many incorrectly bill an additional office visit with the procedure using modifier -25, putting themselves at risk during an audit.
CPT code 68761 defines the “closure of the lacrimal punctum, by plug, each,” so additional modifiers that specify the lid—E1, upper left lid; E2, lower left lid; E3, upper right lid; E4, lower right lid—must be used when coding for punctal occlusion.
• Amniotic Membranes. CPT code 65778—“Placement of amniotic membrane on the ocular surface; without sutures,” with a 10-day global period—is also growing in popularity in ophthalmic practices. With respect to OSD, amniotic membranes are generally reserved for more advanced disease, as you are not treating the dry eye, but are treating the corneal sequelae of the OSD. Moreover, not all amniotic membranes are created equal, and CMS has noted, in a recent Local Coverage Determination:
“Amnion can be prepared for implantation a number of ways. Heat- or air-dried amniotic membrane loses some of its biologic properties and is not ideal for ocular surface rehabilitation. The tissue can be lyophilized (freeze-dried), which induces minimal change in its properties. Amnion can be preserved in cold glycerol and cryopreserved and stored frozen at -80 degrees. The cryopreservation method allows for greater retention of the membrane’s structural, physiological and biochemical properties responsible for its dramatic healing and easier handling intraoperatively.”
While it’s tempting to use less effective technology to increase profitability, it may not be a wise choice.
|Economic Potential of Dry Eye in the Average OD Practice2|
|Number of Americans with dry eye||78,500,000|
|Median patient volume in an optometric practice per year||3,100|
|Overall incidence of combined dry eye||25%|
|Dry eye patients in an optometric practice per year||775|
|Average reimbursement for dry eye-related office visit||$73|
|Typical number of office visits for a dry eye patient per year (non-punctal occlusion)||3|
|Potential revenue from dry eye office visits per year (non-punctal occlusion)||$164,633.25|
|Typical revenue from a Medicare punctal occlusion patient||$756.88|
|Typical revenue from a non-Medicare punctal occlusion patient||$1,336.60|
|Percentage of patients undergoing punctal occlusion||3%|
|Potential punctal occlusion revenue from Medicare patients per year (assuming half the practice’s volume is Medicare patients)||$8,798.73|
|Potential punctal occlusion revenue from non-Medicare patients (assuming the other half of the practice’s volume is non-Medicare patients)||$15,537.96|
|Potential revenue due to dry eye per year||$188,969.94|
|Lifetime economic potential of diagnosing and treating dry eye||$8,503,647|
For CMS, a separate charge and reimbursement for the supply of the amniotic membrane is not allowed, as it’s bundled into the reimbursement for the procedure, not unlike the rationale used for punctal plugs. However, other commercial carriers may have policies that allow for reimbursement of the procedure and the materials. If so, the appropriate HCPCS Level II code is V2790 (“Amniotic membrane for surgical reconstruction, per procedure”).
Other new technologies, separately identified by either a Level III HCPCS code or a new CLIA-waived procedure, can be coded in addition to the office visit:
• CPT code 83516—immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semi-quantitative, multiple step method—is now a CLIA-waived test (be sure to use the modifier –QW on each procedure performed). It can be performed in optometrists’ offices that have a clinical lab designation and a physician with the practice has been registered as a clinical lab director. The current national payment amount for this lab test is $15.71 per eye.
• 0330T—tear film imaging, unilateral or bilateral, with interpretation and report—is a temporary use or “tracking code” for tear film interferometry. It needs to be reported to the carrier, but is generally a patient payable test. Be aware that there are coordinating rules with CPT code 92285 (anterior segment photography) for this code.
Optometrists basically wrote the book on dry eye. It’s a daily occurrence in our patients’ lives, and it has nothing but opportunity written all over it when embraced by optometry. It is a growing area of concern, focus of research and service demanded by patients. New technology is always exciting when employed within our practices to provide new avenues to great patient care. But it also requires that we keep up with the appropriate recording and reporting mechanisms that are in place for appropriate compliance.Send questions and comments to ROcodingconnection@gmail.com.
1. Ezuddin NS, Alawa KA, Galor A. Therapeutic strategies to treat dry eye in an aging population. Drugs Aging. 2015 Jul;32(7):505-13.
2. Rumpakis J. Economics of Apathy. Review of Optometry. 2013;150(10):24.