Blepharitis

Find the proper documentation requirements and reimbursement potential for diagnosing and treating dry eye syndrome.

Keratoconjunctivitis sicca (KCS), also known as dry eye syndrome (DES), affects 14.4% of patients between the ages of 48 and 91. This condition commonly develops with increased age and is more prevalent in patients over 60, especially in postmenopausal women. Patients with DES suffer from persistent corneal dryness secondary to decreased tear gland function, increased tear evaporation or environmental irritations. Left untreated, DES can cause corneal thickening and, eventually, impaired vision.

How prepared are you to diagnose and treat DES? This article reviews current protocols, including new drug therapies, and provides the appropriate codes to help you get reimbursed.

Dry eye indicators

ICD-9-CM identifies various dry eye conditions, each differing in severity and prevalence (see "ICD-9-CM Codes for Dry Eye Syndrome"). Although DES may present as a single condition, it's frequently associated with other ocular and systemic conditions. Some systemic diseases strongly associated with DES include: Arthritis, thyroid disease, gout and diabetes.

Dry eye syndrome can develop when malfunctioning lacrimal glands secrete fewer tears, disrupting the tear film and causing ocular discomfort. Dry eye syndrome also may be associated with inflammatory diseases including:

* Rosacea

* Sjögren syndrome

* Rheumatoid arthritis.

Other factors contributing to DES include:

* External eye diseases, such as herpes zoster and blepharitis

* Corneal surgery

* Systemic medications affecting tear production.

Dry eye syndrome symptoms can worsen with the use of antihistamines, certain diuretics, antidepressants and other medications. Smoking and caffeine use also contribute to DES.

Patients may experience more severe symptoms with exposure to environmental conditions, such as wind, air conditioners or heaters, or during activities that reduce blink rate, such as extended periods of reading, computer work or driving. Just as causes for DES vary, so do treatment options.

Consider proper codes

Patients usually are diagnosed with DES after undergoing physical examination and diagnostic testing for changes to the tear film and lacrimal insufficiency. Physical examination usually reveals reduced tear volume or quality, decreased tear break-up time and corneal surface changes.

Because DES is a medical condition, your claims for reimbursement should be submitted to Medicare or other medical insurance, not to vision insurance carriers, which cover routine eye care, eyeglasses and contact lenses.

In a quest for straightforward coding guidance, eyecare professionals often ask, "What code is appropriate to report an eye exam for dry eye patients?" Unfortunately, there's no single answer.

Depending on the severity of the condition and the components of the examination, you may choose from a wide variety of evaluation and management (E/M) codes and eye codes (Current Procedural Terminology [CPT] 920xx).

A problem-focused exam may be all that's necessary for a follow-up visit with a DES patient who is comfortable receiving symptomatic relief with artificial tears. An intermediate eye exam is warranted for a patient who complains of worsening symptoms and is not satisfied with his current treatment regimen.

A comprehensive exam is justified for a new patient with DES exacerbated by proptosis due to Graves ophthalmopathy. This patient warrants a thorough history and exam due to multiple contributing conditions.

CPT's definition of intermediate eye exams states "...an evaluation of a new or existing condition complicated with a new diagnostic or management problem..." Now how do you document these patients?

Documenting dry eye

Regardless of the CPT code you choose to report the exam, basic documentation of a DES patient should include:

* Patient's name and date of service

* Chief complaint or reason for the visit (for more information, see "Documenting Chief Complaint")

* Appropriate medical history pertaining to the reason for the visit

* Documentation of all examination components performed while assessing the condition. Be sure to document positive findings as well as pertinent negative findings.

* An order and interpretation for all diagnostic tests performed

* Impression or diagnosis

* Treatment plan or discharge instructions.

Depending on the nature of the treatment plan, you may need to document failure of a primary treatment course.

After determining a patient's chief complaint, thoroughly document his past ocular and general medical history, including any factors that could affect the external eye examination. For example, you should ask about:

* History of corneal, refractive or eyelid surgery

* History of exposure to chemicals or irritants

* Contact lens history including type(s) of lenses worn, wearing time and cleaning regimen, including brands of solutions and symptoms experienced with contact lens wear

* History of other ocular conditions including injury and infection

* History of eyelid conditions, including Bell's palsy, lid malposition, injury or trauma

* Current medications, chronic conditions, allergies and symptoms of menopause

* Social history, including history of smoking and activities/hobbies that may make symptoms more pronounced.

Coding consultations

In some instances, patients with chronic or severe DES are referred to a specialist for consultation and possible treatment.

The specialist may bill his service using the outpatient consultation codes (CPT 9924x) as long as all criteria are met. These criteria, according to Medicare (effective Aug. 26, 1999), include the following points:

1. Another physician, other appropriate source (such as a nurse practitioner or physician's assistant) or the patient (for confirmatory consultation) requests the advice or opinion of a consultant, either verbally or in writing.

2. The medical record must document a request from an appropriate source, as well as the need for the consultation.

3. The consultant must take the patient's history and perform an examination; diagnostic procedures may be ordered separately.

4. The consultant must send a written report containing his findings and recommendations to the referring physician to become part of the patient's permanent medical record. A copy is also kept in the consultant's files.

5. The attending physician does not transfer care to the consultant. Transfer of care occurs when the referring physician transfers responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents acceptance of care in advance.

All these criteria must be met for an examination to qualify as a consultation.

Whether using office visit codes or consultation codes, higher-level CPT codes generally are reserved for examinations that address very serious or complicated conditions.

Use caution when selecting a level 4 or 5 ?/M code for DES. These levels of service - comprehensive and complex exams - usually require a dilated fundus examination. The payer might question medical necessity for such an examination for a mild condition that can be addressed in a straightforward manner.

Evaluating the tear film

You may need to perform additional diagnostic tests to confirm a DES diagnosis after you complete your initial evaluation.

Schirmer's tear test is one of the most common to measure tear quality, whereas other tests, such as tear break-up time, measure the quality of tear composition.

Many cornea experts use either rose bengal or lissamine green drops to test for DES (see "Visualizing Dry Eye" for more information). These agents stain conjunctival and corneal cells that tend to keratinization to identify damage to the surface of the eye. While light staining does occur in normal patients, moderate staining is characteristic of KCS and intense staining indicates patients who are likely candidates for stronger intervention than artificial tears, such as prescription medications.

Usually, separate reimbursement isn't provided for these tests; they're incidental to the office visit (see "Coding Tear Tests"). Nevertheless, this testing is helpful to assess the severity of the dry eye condition and plan future treatment, either via medical therapy or punctal occlusion.

Prescription medication for treating dry eye

Primary treatment for mild DES usually begins with artificial tears, gels and lubricating ointments. Patients with persistent DES who aren't satisfied with these palliative measures may benefit from a therapeutic option that treats the underlying cause of dry eye disease, cyclosporine ophthalmic emulsion 0.05% (Restasis).

In clinical trials1 of cyclosporine ophthalmic emulsion 0.05%, researchers reported that patients experienced improvement in photophobia, itching, dryness and blurred vision in the first month of therapy. What's more, during the course of treatment, patients' goblet cells increased 191% over vehicle, demonstrating that cyclosporine ophthalmic emulsion 0.05% produces normal, healthy tears that support the ocular surface effectively.

If medical therapy is not effective, surgery, including punctal occlusion, may be an option. A recent study2 comparing the concurrent use of lower lid punctal occlusion and cyclosporine found the two agents appeared to act synergistically in the treatment of DES.

Surgical strategies

Surgical intervention usually is reserved for patients with more severe symptoms or as a secondary approach when medical therapy has failed.

Before considering surgical intervention, be sure the chart documents that less invasive therapy using eye drops failed to improve symptoms. Failure can be attributed to:

* Ineffective medication

* Patient's noncompliance

* Patient's inability to administer topical medications

* Limited financial resources preventing patients from using prescribed medications on an ongoing basis.

Surgical treatment for DES runs the gamut from complex procedures, such as tarsorrhaphy, to relatively simple punctal occlusion.

According to the Clinical Practice Guideline (CPG) "Care of the Patient with Ocular Surface Disorders" (CPG10), prepared by the American Optometric Association, inserting punctal plugs is a reasonable course of action after initial medical therapy.

Whether you're placing temporary diagnostic collagen plugs or longer-lasting silicone or thermosensitive acrylic plugs, reimbursement is the same: A single payment that covers the procedure and the plug.

To receive reimbursement for punctal occlusion, be sure to include proper documentation on the patient's chart. In addition to the exam, which describes the indications, your notes should include the patient's consent to proceed, an operative note and discharge instructions.

Although the operative report need not be lengthy, it should contain enough information so a reviewer can understand what procedure was performed. For example:

* Which puncta were involved?

* What plugs were used, described by type (collagen, silicone, acrylic), brand and size?

* Did the patient receive topical anesthesia?

Similarly, discharge instructions are fairly straightforward for this minimally invasive procedure. A short note stating, "patient tolerated procedure well. Was instructed not to rub eyes and to call our office if he experiences pain or discomfort" usually is adequate.

Finally, professional liability insurance carriers prefer a written consent, but the patient's verbal consent is adequate if you document it. Once you've performed the procedure, how will you code and bill for it?

Coding punctal occlusion

The CPT book provides two separate codes for punctal occlusion:

68760: Closure of lacrimal punctum by thermocauterization, ligation or laser surgery

68761: Closure of lacrimal punctum by plug, each.

By definition, reimbursement for these procedures is per punctum, not per eye. Medicare's physician fee schedule for participating optometrists allows $140 for 68761; 68760 does not fall within the scope of optometry. This rate is down slightly from the peak in 2001 but still represents a reasonable reimbursement for this service.

When more than one punctum is involved in the same session, the subsequent procedures are reimbursed at 50% of the allowed amount, consistent with Medicare's multiple surgery rules.

For example, if the two lower puncta are occluded with plugs at the same time, then Medicare reimbursement is $140 for the first punctum and $70 for the second punctum, minus applicable copayment and deductible. Reimbursement rates for other third party payers vary but generally are comparable.

Many patients- require punctal dilation to facilitate plug insertion, prompting practitioners to ask whether this is a separately billable service under the Medicare program.

The National Correct Coding Initiative (NCCI) edits bundle this procedure (CPT 68801) with the insertion of punctal plugs. Additional bundled codes (effective Oct. 1, 2005) are listed in the NCCI edits.

Medicare plug reimbursement

Before Jan. 1, 2002, Medicare paid separately for the supply of permanent punctal plugs (temporary plugs always have been included in the procedure reimbursement).

The Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare to describe punctum plugs were A4263 (supply code for silicone plug, each) and A4262 (supply code for collagen plug, each).

Medicare no longer pays separately for the supply, although some commercial carriers may continue to pay for the supply. In these cases, use 99070 (miscellaneous supply) to describe the plug(s).

Use the "units" column of the claim form to note the number of plugs inserted. Some payers require a copy of the invoice for description and cost.

The 1999 Medicare Physician Fee Schedule addressed the supply issue (Nov. 2, 1998 Federal Register, Vol. 63, No. 211, pg. 58831-58832). The Balanced Budget Act provided for a 4-year transition period to implement a new resource-based system for calculating Medicare reimbursement of physician services.

As part of this transition, CMS decided that supply costs for punctal occlusion were already included in the new, higher procedure reimbursement; so separate payment for supplies has been phased out.

According to Medicare Part B Extract and Summary System (BESS) data for 2003, punctal occlusion with plugs (68761) is the fourth most commonly performed ophthalmic surgical procedure.

Optometrists performed this procedure 119,000 times on Medicare beneficiaries, or two times for every 100 eye exams in this population.

The factors that contributed to the rapid growth of punctal occlusion in the Medicare program include:

* Many beneficiaries with DES

* Widespread dissatisfaction with artificial tears

* The efficacy of punctal occlusion with plugs

* Relatively safe and simple office-based procedure

* Attractive reimbursement.

Any time payers see a rapid increase in payments, scrutiny of the claims is sure to follow (for a worst-case scenario, see "Don't Overuse Punctal Plugs").

Look for a possible increase in audit activity for CPT code 68761 as payers verify they're reimbursing medically appropriate procedures.

Explore your options

Dry eye syndrome is a complicated disease, presenting eyecare professionals with clinical, coding and reimbursement challenges.

You can avoid many common obstacles and improve your reimbursement by using treatment protocols reasonably, adhering to community standards of care and remaining cognizant of claim submission and reimbursement protocols.

REFERENCE:

1. Sail K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107:631 -639. Erratum in: Ophthalmology. 2000;107:1220.

2. Robert CW, Carniglia PE, Brazzo BG. Comparison of cyclosporine to punctal plugs in relieving the signs and symptoms of dry eyes. Presented at the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO); May 1-5, 2005; Ft. Lauderdale, Fla.

By Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O. San Bernardino, Calif.

Copyright Boucher Communications, Inc. Nov 2005
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