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Find out what tests physicians use to make a diagnosis.

Itchy? Stinging? Burning? Gritty?

When the eyes do not produce enough natural tears, or when the tears evaporate too quickly, the condition is commonly known as dry eye. Sometimes called keratoconjunctivitis sicca, patients may experience a scratchy sensation, may feel like they have something in their eyes when they don’t, may have tired eyes, or may experience watering from irritation. Roughly 15 million Americans suffer with dry eyes.

Read on to learn how to code different dry eye conditions.

Familiarize Yourself With Common Dry Eye Conditions

Dry eye syndrome (DES), H04.12- (Dry eye syndrome), also known as tear-film insufficiency, occurs when the eye does not produce enough natural tears or when the tears evaporate too quickly, leading to discomfort and irritation on the eye’s surface.

Keratoconjunctivitis (KCJ), H16.22- (Keratoconjunctivitis sicca, not specified as Sjogren’s), is a more specific form of dry eye which causes inflammation of both the corneal and conjunctival layers due to insufficient tear production. “Kerato” identifies the cornea, while “conjunctivitis” is an irritation of the conjunctival layer.

These two terms are often used interchangeably, but KCJ is a more severe condition than DES. The complete ICD-10-CM for each code is six digits in length, with the last digit specifying laterality: 1 for right eye, 2 for left eye, or 3 for bilateral.

Example: Bilateral dry eye syndrome is coded as H04.123 (Dry eye syndrome of bilateral lacrimal glands).

Meibomian gland dysfunction (MGD), H02.88- (Meibomian gland dysfunction of eyelid), affects glands located along the eyelids that secrete an oil called meibum onto the surface of the eye, which helps to slow the evaporation of tear film. When these glands are clogged or otherwise affected, the meibum cannot reach the eye, and that can result in dry eye symptoms and sensations. You need six characters to specify which eyelid or eyelids are affected. The ICD-10-CM code may end in a number for a specific lid, or the final character may be A for both eyelids of the right eye or B for both eyelids of the left eye.

Example: MGD of both lids of the right eye is coded with H02.88A (Meibomian gland dysfunction right eye, upper and lower eyelids).

Blepharitis, inflammation of the eyelids, generally occurs due to clogged oil ducts near the base of the eyelashes. This inflammation has an adverse effect on tear film, leading to dry eye effects. There are various types of blepharitis under ICD-10-CM parent code H01.0- (Blepharitis). Each condition is further defined by a 5^th character for condition specificity and a 6^th character for laterality.

Sjogren’s syndrome with keratoconjunctivitis, M35.01 (Sjogren syndrome with keratoconjunctivitis), is an autoimmune disorder where the immune system attacks moisture-producing glands in the body and can cause dry eye from the effect on tear production.

Know How the Physician Diagnoses the Patient

When dry eye symptoms become severe, diagnosis will be made with a thorough and comprehensive examination. Once the diagnosis is confirmed, a treatment plan will be implemented to manage symptoms. Periodic exams are necessary to evaluate the effectiveness of the treatment and adjustments to treatment are made accordingly.

Initial examination will include a detailed review of health history, lifestyle, environmental factors, and any other components which may bear on the condition. Tests such as, but not limited to, tear breakup time (how long it takes for a dry spot to appear on the cornea after a blink) and a Schirmer test (paper strips placed inside the lids to measure tear output) may be employed during the exam.

Important: These basic tests are considered part of the workup and are not separately billable. Other tests may be performed as noted below.

Periodic follow-ups may or may not repeat testing, depending on the effectiveness of the established plan of care and its effect on symptoms.

• Scenario 1: A new patient presents with complaints of persistent dry eye symptoms, a thorough evaluation is completed, and a prescription eye drop is initiated. When documentation supports the ongoing nature of the condition, this may be labeled as chronic with progression, meeting the moderate threshold for problem complexity. Combined with the moderate risk level inherent in prescription management, this evaluation and management (E/M) visit meets the criteria for 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.).
• Scenario 2: The same patient returns for a follow-up visit in three months. The symptoms are well managed, and the patient has no new or additional complaints. Though the provider determines to continue the prescription eye drop, the condition is now documented as stable chronic. With moderate risk but low problem complexity, this E/M visit codes to 99213 (… established patient … low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.).

Beyond the standard tests often incorporated into an evaluation, severe symptoms may warrant additional testing as available. These tests are uniquely performed and offer a more comprehensive assessment of the condition as well as a source of additional revenue.

Below are examples of additional codes for dry eye testing:

• 83861 (Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity): Commonly called a tear osmolarity test, this test measures the osmolarity levels in human tears. Osmolarity is the amount of salt concentration in tears; above normal levels indicates issues with tear production and/or evaporation. This is a unilateral test, so be sure to append modifiers RT (Right side) and LT (Left side) to two entries of 83861 for bilateral examinations. A QW (CLIA waived test) modifier will also be appended to signify status as a Clinical Laboratory Improvement Amendment (CLIA) waived test.
• 83516 (Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method): A tear sample collected from the lower eyelid is tested for metalloproteinase-9 (MMP-9) matrix levels, an inflammatory marker present in tears. The presence of the marker signifies ocular inflammation, which aids in determining a course of treatment. This test is unilateral, so you’ll code 83516-RT and 83516-LT when the provider performs the test bilaterally. Append modifier QW to denote a CLIA waiver for the testing.

The CLIA program sets lab regulations for standards for patient health and safety for lab tests on human specimens. Waived tests are simple tests with minimal effort, minimal training, and minimal interpretation, with a low likelihood of error. A CLIA certificate of waiver is still required when tests do not come under the regulation of the CLIA program; modifier QW is appended to a waived test to indicate the waiver has been obtained.

Code Treatments When Applicable

Basic management of dry eyes begins at home. Eyelid scrubs, warm compresses, or artificial tears are over-the-counter remedies and a patient’s first-line defense against the effect of symptoms. Prescription drops are constantly evolving (you have likely seen commercials and maybe hummed the jingles).

Many patients find relief with the insertion of punctal plugs. Plugs are tiny devices the physician inserts into the puncta, which are openings in the eyelids where tears drain. Placement of plugs blocks the puncta from draining, thus retaining natural tears on the surface of the eye. The plugs come in different materials: collagen, which dissolves over time and needs periodic replacement; or silicone, which is permanent. Report 68761 (Closure of the lacrimal punctum; by plug, each), using one line for each plug inserted. Make sure to append the appropriate eyelid modifier(s), E1-E4, for the placement location.

Additional treatments continue to evolve, aimed at cleaning debris from eyelids, massaging or applying heat to encourage the release of clogged oil glands, or directing intense pulsed light to improve tear quality and reduce inflammation. However, these are elective procedures, considered self-pay, and are not codeable or billable to payers.

Dry eyes can be a nuisance, a source of discomfort, or an outright pain for the patient. But thorough evaluation and individualized treatment protocols enable physicians to decrease their patient’s discomfort and increase better vision.

Christine Killeen CPC, CPB, COPC, Contributing Writer