What Can You Do?

Contact lenses contribute to ocular dryness by acting as a moisture sink, decreasing corneal sensation and disrupting the mucin layer of the tear film. This is especially important to consider because research has often cited that discomfort due to dryness is the number-one reason why patients drop out of contact lens wear.

Keep in mind that instead of complaining to you about discomfort, many of these patients gradually drop out of contact lenses and drop out of your practice.

What can you do to stop these patients from dropping out? First, start with a rehabilitated eye. Whether you prescribe artificial tears, punctal plugs or mild steroids, always underscore the fact that dry eye can develop into a serious medical condition, so every patient should always return for proper follow up.

Follow the medical model for dealing with dry eyes. This includes proper documentation of the patient's condition and proper follow-up care.

Practitioners also should recommend refitting the patient into Proclear contact lenses.

Following the Protocol

When performing a complete eye exam on a patient complaining of dry eye symptoms, document the patient's complaints and perform appropriate diagnostic tests such as tear break-up time (TBUT), Schirmer, phenol red, rose bengal or lissamine green testing. Code for the initial comprehensive eye examination, new (92004) or established (92014). Then, code follow-up visits with the appropriately documented and justified evaluation and management code. Most often this would be an established level 3 (99213).

Provide the patient with a sample of a low-viscosity artificial tear to determine its effectiveness. Lubricating eye drops and artificial tears are appropriate for patients who have mild dryness complaints. Bill this component of the examination to the patient's medical insurance.

If your patient wears contact lenses, ask him specifically if he experiences any discomfort and ask about average wear time. The reality is that nearly all patients want to wear their contact lenses all day. If they're not, make sure you find out why.

If the patient complains about decreased wear time, then fit him in Proclear Compatibles. While I prefer Proclear, others mention changing solutions or switching to silicone hydrogels, daily disposables and Extreme H₂O lenses (Hydrogel Vision Corp.). In addition to the comprehensive eye exam (which you bill to the patient's medical insurance), you can charge a separate lens refitting fee, which the patient will either pay out of pocket or bill to a vision plan.

What you do next is the key: Have the patient return for a dry eye follow-up visit in one to two weeks. Tell the patient that artificial tears are only one way to treat dry eye and that further evaluation will reveal their effectiveness. If they don't work, there are other options that you can utilize to help resolve the problem.

Dry Eye Follow-Up

If your patient received adequate relief from the artificial tears, then bill the appropriately documented and justified evaluation and management code (992XX). Reinforce at this visit that Proclear Compatibles are the best lens on the market for ocular dryness.

If your patient still complains of dry eye symptoms, consider switching to high-viscosity drops and/or lubricating ointments. These supplements last longer, but may periodically blur patients' vision, which is why qhs dosing is usually the best option. Alternatively, you may discuss the need for punctal plugs. If you change the patient's medical regimen, then see him again for a follow-up visit in one to two weeks to check for efficacy.

If you do insert punctal plugs, use 68761-E2 for the right lower punctum and 68761-E4 for the left lower punctum.

Have the patient keep track of symptoms and return for a follow-up exam in roughly two weeks. Many may no longer need lubricating drops while others will notice a decreased dependency on them. Once again, bill both the office visit and punctal plugs to the patient's medical insurance.

Dry Eye Documentation

As primary eyecare providers, most of us are comfortable managing patients who have dry eyes. This, however, adds the burden of properly coding and getting reimbursed for these patients. This is especially true because revenue from the materials part of contact lens fitting has decreased significantly over the past several years. More of us are losing lens prescriptions to outside sources or we have to lower our prices to compete. However, when it comes to dry eyes, using Proclear Compatibles as a therapeutic lens can help offset some or all of the lost revenue.

The key here is to be consistent and to provide adequate documentation. In general, proper reimbursement for testing done on dry eye patients depends on the following four factors:

• Proper coverage for the service

• Proper justification for the service

• Proper documentation of the service

• Proper coding on the claim form (CPT and ICD-9)

Benefits for All

If you document everything you'll get reimbursed accordingly.  By following a protocol to treat your contact lens patients' dry eye, both your patients and your practice will benefit.

Dr. Gupta practices full scope optometry and is a clinical director of The Center for Keratoconus at Stamford Ophthalmology.