Optometry Coding & Billing Alert

Nearly $150 is at stake each time.

With nearly 78.5 million Americans suffering from dry eye, there is a lot at stake for optometry practices, according to information recently released by the Review of Optometry – offices usually see about 775 dry eye patients per year, and may earn roughly $189,000 per year from dry eye patients alone.

With several treatment options, including punctal occlusion, on the table, it’s critical to keep track of your CPT^® and ICD-10 coding, to give the payer a complete clinical picture of your patient’s condition and what you’ve done to address his dry eye.

Get to Know the Condition

Dry eye syndrome occurs when the tears aren’t able to provide adequate lubrication for the eyes, according to the Mayo Clinic. The amount of tears themselves may be inadequate, or the tears may be poor-quality.

Watch for: The patient may complain of redness, stinging or scratchiness, irritation, light sensitivity or blurred or fatigued vision, among many other signs and symptoms.

There are a few ICD-10 codes that describe dry eye syndrome, but the most common ones are:

• H04.121 – Dry eye syndrome of right lacrimal gland
• H04.122 – ...of left lacrimal gland
• H04.123 – ...of bilateral lacrimal glands
• H04.129 – ...of unspecified lacrimal gland
• H16.221 –Keratoconjunctivitis sicca, not specified as Sjögren’s, right eye
• H16.222 –...left eye
• H16.223 –...bilateral
• H16.229 – ...unspecified eye.

What’s included? A note in ICD-10 specifies that the H04.12x codes include “tear film insufficiency NOS.” Keratoconjunctivitis is an inflammation of the cornea and conjunctiva; keratoconjunctivitis sicca refers to inflammation caused by dryness.

Other diagnoses you may see include:

• H16.141 – Punctate keratitis, right eye
• H16.142 – ...left eye
• H16.143 – ...bilateral
• H16.149 – ...unspecified eye
• H16.211 – Exposure keratoconjunctivitis, right eye
• H16.212 – ...left eye
• H16.213 – ...bilateral
• H16.219 – ...unspecified eye
• M35.01 – Sicca syndrome with keratoconjunctivitis.

“Sicca syndrome” is also known as “Sjögren’s syndrome,” a chronic autoimmune disease which attacks the lacrimal glands.

Tip: Base your ICD-10 code on your clinical findings, not the patient’s complaint. Example: If the patient complains of a foreign-body sensation, and you see diffuse punctate staining, punctate keratopathy, epithelial defects, sterile corneal ulcers, corneal vascularization, or corneal scarring in both eyes, then you may want to diagnose dry eye with H16.223. But if a tear volume test reveals low tear volume, H04.123 may be the appropriate choice.

Plug Away with Proper Procedure Coding

The insertion of punctal plugs is one of the most common treatments for dry eye – but before you take that step, many payers want you to try other therapies, such artificial tears. Generally, those therapies would not be separately billable, instead included in an E/M (99201-99215) or eye exam (92002-92014) CPT^® code.

Also included in the examination is the Schirmer’s test, with uses paper strips to measure the production of tears. There is no separate CPT^® code for this procedure; the Schirmer’s test is one of many diagnostic procedures that cannot be coded separately from an E/M code or eye code, warns Becky Shimanek, CPC, coding manager for Aviacode, who led a seminar on “Ophthalmic Diagnostic Tests” at the recent CodingCon 2015 conference.

Turning to plugs: Once those avenues are exhausted, you will most likely turn to punctal plugs – CPT^® code 68761 (Closure of the lacrimal punctum; by plug, each). When the patient is appropriately prepped, the optometrist may instill drops to anesthetize the eye. He dilates the punctum to make it easier to insert the plug. He uses a disposable forceps-like device or syringe to insert the plug. Depending on the material, plugs may be temporary or semipermanent. The provider releases the patient after a short recovery period.

Note that lacrimal dilation is included in this procedure – do not report CPT^® code 68801 (Dilation of lacrimal punctum, with or without irrigation) separately.

Specify Eyelids with Modifiers

Medicare has created four modifiers to specify eyelids: E1 (Upper left, eyelid), E2 (Lower left, eyelid), E3 (Upper right, eyelid), and E4 (Lower right, eyelid).

Pitfall: If you place plugs in all four lids, you would not report modifier 50 (Bilateral procedure), as that would indicate you only placed two plugs, not four. However, most private non-Medicare providers will want the LT (Left side) and RT (Right side) modifiers, not the E1-E4 modifiers.

Check Payer Rules for Reduced Payments

Medicare values CPT^® code 68761 at 4.17 relative value units (RVUs) in the 2016 Medicare Physician Fee Schedule. Multiplied by the 35.8043 conversion factor, this means typical reimbursement for a punctal plug insertion is $149.30 in a non-facility setting, which helps explain the $189,000 yearly figure the Review of Optometry estimates for your dry eye treatments.

However: Some carriers may reduce payment for subsequent plug placement – be sure to check with your individual payer for its rules.