Billing and Coding in Dry Eye: Showing Medical Necessity Can Ensure Reimbursement

Cecelia Koetting, OD, FAAO

With so many recent advances in diagnosing and treating dry eye disease, ensuring all procedures get reimbursed can be complicated. Having a dedicated coding and billing specialist in your office is well worth the investment to be sure all the details are correctly taken care of.

Deciding which treatments to offer in the office is the first step, and an important factor of those decisions is how, or if, we’re going to be reimbursed for utilizing the ones we choose. The most important thing to remember is that coding needs to be driven by medical necessity. If you can prove medical necessity you can bill for the testing or procedure. And this can be accomplished with thorough documentation of the signs and symptoms that prompted the testing or procedure, along with interpretation of the testing.

For instance for a diagnosis of dry eye, you start by getting a SPEED score for all your patients, to show that they have a chief complaint that acknowledges some of the problems may be related to dry eye. These may be fluctuating vision, occasional stabbing or aching pains, a dry eye feeling or a feeling of grit in their eyes. And then you back that up by doing more testing. You’ve got the complaint, so now you can back it up with the codes of dry eye, MGD, whatever is applicable.

Unfortunately, there are tests and treatments we do in the office that we don’t get reimbursed for, for example meibography, which a lot of people are doing now. It does technically have a code, but we’re not able to get reimbursed. In a case like this the insurance companies need to be shown that there is a medical necessity. It’s a long process, but sending them case studies and evidence that it does help patients can drive the need for them to cover the cost.

Below I’ll discuss a few of the more commonly used in-office procedures and diagnostic devices that are considered reimbursable by insurance.

CPT Code 65778 (placement of amniotic membrane on the ocular surface; without sutures) (0 day global period)

This code is used for both dry and cryopreserved amniotic membranes. This is covered by Medicare and many other insurances when medically necessary, but the coverage policy should be checked, and prior authorization obtained if required. See the table below for a list of the most used and reimbursed ICD-10 codes pertaining to dry eye.

Reimbursement for this CPT code based on 2018 Medicare Physician Fee Schedule (MPFS) was $1,448 in office, and then adjusted by local wage indices. Other payers set their own fee schedule, so this will differ. The amniotic membrane is not paid for separately and you cannot bill CPT code 92071 fitting of contact lens for treatment of ocular surface disease along with this code. You also cannot bill for an office visit on the same day that the procedure is performed.

CPT Code 68761 (closure of lacrimal punctum; by plug, each) (68761-50 for bilateral) (10 day global period)

This code does not make a distinction between the different types or brands of punctal plugs. Depending on the insurance “E” modifiers may be used to identify which punctums were occluded; others will accept RT (right eye) and LT (left eye) on the claim. Your ICD-10 diagnosis codes should indicate which eye(s) is treated. Most commonly diagnosis codes of dry eye syndrome or keratitis sicca are used, but other conditions can support this as well (see table). If appropriate, an office visit on the day of punctal plug insertion can be billed using modifier 25 appending the office visit code.

Reimbursement for this CPT code based on 2020 MPFS for this in-office procedure is $152, which is then adjusted by local wage indices. If two puncta are occluded at the same appointment it is considered multiple surgeries which means the first procedure (puncta) is reimbursed at 100% and the second reimbursed at 50%, third and fourth at 37.5% each.

Diagnostic testing. Multiple tests and even similar tests can be performed on the same day; however, it is important to link the procedure code to the correct diagnosis code. It is also good to be aware of reimbursement rates for each test. Typically the first test billed will be reimbursed at full rate with each subsequent test reimbursed at a lower rate.

CPT Code 83861 (Microfluidic analysis utilizing an integrated collection and analysis device; tear osmolarity)

Tear osmolarity testing, such as TearOz (TearLab), is billed for each eye using the CPT code twice on two lines with the laterality modifier LT or RT. Some carriers may deny the second tested eye and may need to be submitted as 83861 once on one line with no modifiers but with 2-units of service. A list of acceptable diagnosis codes to be used for TearOz can be found here.

Based on 2018 CMS fee schedule reimbursement for the test is $22.48 per test, varying per state limits. It will only be reimbursed to those providers who maintain CLIA certificate or a CLIA waiver certificate. If you have a CLIA waiver certificate for your office, you will also need to use a QW modifier along with the laterality modifier; 83861-QW-RT.

CPT Code 83516 (immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semi-quantitative, multistep method)

Like tear osmolarity, Inflammadry (Quidel) requires a CLIA certificate or waiver certificate for Medicare or Medicaid. The modifier of QW is used in those offices with a CLIA waiver. When performing this test bilaterally most payers prefer the use of a 59 modifier for the second eye as well as the laterally modifiers RT and LT. This test should be billed with CPT code twice on two lines with needed modifiers for each eye tested. Since there are more modifiers with this test, it may be worth checking with your payers and keeping track of who requires what modifiers.

Reimbursement based on the 2017 CMS fee schedule for this code was $15.82 for the first test with varying state limits. Commonly used and accepted ICD-10 diagnosis codes used along with Inflammadry testing are found in the table below.

Side Note: LipiScan/LipiView (J&J) or meibography technically has the code 0330T for tear film imaging unilateral or bilateral with interpretation and report. However, at this time there is no reimbursement associated with this code and the patient usually pays for it.

Reference(s):

Reimbursement for amniotic tissue. https://www.corcoranccg.com/products/faqs/amniotic-tissue/#:~:text=A%3A%20CPT%20code%2065778%20describes,ocular%20surface%3B%20without%20sutures. Accessed 4/19/2021
Medicate reimbursement for punctal occlusion by punctal plug. https://www.corcoranccg.com/products/faqs/punctal-occlusion-oasis/. Accessed 4/19/2021
ICD coding for Dry Eye https://www.tearlab.com/pdfs/Reimbursement/940089_Rev_B_-_ICD-10_Coding_for_Dry_Eye_-_FINAL_-_1-16-16.pdf. Accessed 4/19/2021
Coding guidelines - dry eye. https://www.quidel.com/sites/default/files/product/documents/IN1024000EN01.pdf. Accessed 4/19/2021

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