DRY EYE PRACTICE

Building a Dry Eye Practice in 2014

Expanding the dry eye segment of your practice will benefit both you and your patients.

By Clarke Newman, OD, FAAO, & John Rumpakis, OD, MBA

The clinical practice of eye care in 2014 is vastly different from what it was 10 or even five years ago. The rapid advancement in technology and in methodologies to evaluate the incidence and prevalence of disease states, the expanded scope of practice, and even the evolving healthcare delivery system have changed the way in which we provide care for our patients.

Dry Eye Redefined

We cannot think of another disease state in which this phenomenon is more evident than in the clinical diagnosis and management of “dry eye.” With the redefinition of “dry eye disease” in the 2007 publication of the Dry Eye WorkShop (DEWS) report, our world changed, and so did the world of our patients afflicted with this condition. The updated definition formally introduced two new concepts associated with the condition: 1) increased osmolarity of the tear film, and 2) inflammation of the ocular surface. The definition states:

“Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.” (DEWS report, 2007).

Keep in mind that the aim of the DEWS Definition and Classification Subcommittee was to provide a contemporary definition of dry eye disease supported within a comprehensive classification framework. It was the result of a three-plus-year process involving 70 international clinicians, researchers, and industry representatives.

The subsequent publications of the Tear Film and Ocular Surface Society’s (TFOS) Meibomian Gland Dysfunction Workshop in 2011 and the TFOS Report of the Workshop on Contact Lens Discomfort in 2013 further redefined how clinicians need to examine the ocular surface and surrounding structures. For the first time, we had a definitive term for meibomian gland dysfunction (MGD) and evidence of its very significant role in “dry eye.”

As this research permeated the academic and clinical ranks, the very term “dry eye” started becoming obsolete—or, perhaps more accurately stated, insignificant. “Ocular surface disease” and “dry eye disease” are becoming the standard terms under which an entire host of diagnoses are grouped to help us understand the variables at play in managing our patients.

Additionally, as the science continues to unfold, we are truly beginning to understand the effects of comorbid conditions that have multiple etiologies as well as the complexity of managing multiple conditions simultaneously in patients whose corrective needs, lifestyle, and visual demands are constantly in flux.

Let’s take a look at what impact this newly defined disease state can have on your practice.

Motivating Factors

Contact lens usage has remained relatively flat over the last decade, and not enough has not been done to change that. Even with accelerating technological developments in the contact lens arena, many patients aren’t aware of the new technology because they typically don’t ask; and, all too often, if they don’t ask, we don’t tell.

So, if you want to boost your lifetime earnings, stop ignoring the contact lens dropouts in your practice and turn that inaction into something that will increase your profitability. Also, consider that losing a contact lens patient not only costs that revenue stream, but also the “replacement cost” of bringing in a new patient.

Medical eye care is another critical area of potential revenue loss. How so? Eyecare practitioners often don’t recognize medical disease opportunities, aren’t billing for them, or simply refer such patients out of their office. Table 1 shows this, using optometrists as an example (www.aoa.org/Documents/news/state_of_optometry.pdf).

With regard to dry eye, whether it’s aqueous-deficient dry eye, mucin-deficient dry eye, MGD, or contact lens-related dry eye, this condition is a daily occurrence in our patients’ lives and, therefore, within our practices. About 25% to 30% of Americans have clinically recognized dry eye, and a far greater percentage of the population has the associated symptoms. This is another area in which we can better serve patients and benefit economically.

Table 2 shows the economic potential of dry eye patients, again using optometric practices as an example (Rumpakis, 2013). Based on this data, approximately $8.5 million of potential lifetime economic benefit is not captured or recognized to its full potential. We realize that some may question these numbers; in fact, we hope that this article motivates you to examine what is occurring in your own practice. Even if your final calculations don’t match ours, we believe that going through the process of individual analysis will reveal additional opportunities within your practice just waiting for you to act upon.

Getting Started

Starting a “dry eye practice” or a “dry eye center” within your current practice involves several steps.

First, and foremost, the decision to create a focused area of care in your practice demands that you become an expert in that focused area. Whether it is specialty contact lenses, glaucoma, or dry eye management, you must become very well versed in the relevant evidence base. Otherwise, you cannot offer the expert services that you will market to your patient base and to the community.

Obviously, a good place to start is by reviewing the three TFOS dry eye workshop reports; all three are available to the public on the TFOS website at www.tearfilm.org. Another good place to start is by reviewing the various practice patterns and policy statements on this issue promulgated by the various professional groups (i.e., the American Academies of Optometry and Ophthalmology and the American Optometric Association).

Second, you need to decide, using the knowledge that you have accrued, how you plan to diagnose and treat the very complex entity that is dry eye disease so that you can acquire the necessary diagnostic and management tools that you will need. Based on your understanding of the milieu, your budget, and how deep you want to go in this area, you need to develop your protocols and purchase what you need if you do not already have it.

Third, you need to develop an implementation plan that encompasses equipment and supply acquisition, necessary staff additions and training, scheduling changes, electronic health record (EHR) adaptations, marketing plan development, coding and billing strategies, necessary regulatory compliance, patient interview and history forms and scripts, follow-up procedures, and quality metric analysis and compliance.

Getting Equipped

Regarding equipment acquisition, we believe that you have to begin with a quality slit lamp biomicroscope—period. It just stands to reason that if you plan to examine the very complex changes that occur on the ocular surface in dry eye disease, then you had better be serious about the single most important instrument that you will use. A high-quality slit lamp (ideally with a built-in #12 Wratten filter) is the place to start.

After that, there are several instruments that you might want to obtain, depending on your budget. Given the role of inflammation and osmolarity changes in dry eye disease, the next equipment additions that you might want to make would involve diagnostic tools that can assess inflammation and osmolarity. The new InflammaDry Test (Rapid Pathogen Screening, Inc. [RPS]) and the TearLab Osmolarity System (TearLab Corporation) can be helpful in this area.

If you want to use and receive reimbursement for either of these technologies, you will have to get a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver. For guidance in obtaining a CLIA waiver, visit www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/howobtaincertificateofwaiver.pdf. Optometrists in Nevada and New York are not able to get CLIA waivers because of state laws. The Current Procedural Terminology (CPT) billing code for the TearLab Test is 83861. The Healthcare Common Procedure Coding System (HCPCS) modifier used to report a CLIA-waived procedure is –QW. So, you should always append the procedure code for any CLIA-waived procedure with –QW. Remember, your CLIA certificate number goes in box 23.

The InflammaDry Test detects the presence of matrix metalloproteinase (MMP-9), which is upregulated in dry eye disease (Chotikavanich et al, 2009). If you have experience with the RPS AdenoPlus test, then you will know exactly how to perform this test. The CPT code for the InflammaDry test is 83516.

The next big area in dry eye disease is MGD. The process of diagnosing MGD can be as simple as using a transilluminator to examine meibomian gland morphology, or it can be as sophisticated as using the technology in the LipiView (TearScience) ocular surface interferometer. TearScience also offers the LipiFlow Thermal Pulsation System for treating MGD. The LipiView System is billed using the new temporary test imaging code, 0330T; the LipiFlow System is billed using the new temporary code, 0207T. These codes are non-covered services, and there are no established relative value units (RVUs) for these codes.

Some newer corneal topographers, such as the Oculus Keratograph 5M, allow you to perform infrared meibography and tear film analysis. The 0330T CPT code can be used here as well. The ICD-9 diagnosis codes used for these tests are: 375.15—Tear film insufficiency, 373.00—Blepharitis, and 373.12—Hordeolum internum.

Other essentials include some of the more traditional diagnostic elements, such as fluorescein and lissamine green dyes, as well as volume assay tests such as Schirmer’s tear strips and Zone-Quick (Menicon) phenol red thread tests. We use dyes frequently. In fact, Dr. Newman has his dyes compounded in specific concentrations and in a sterile format to eliminate variations is dye performance and results.

Getting Patients on Board

Once you have the technology, you need to develop the scripts that will educate your patients about the services that you provide. Patients are notoriously tight-lipped about dry eye symptoms, especially if they are contact lens wearers. Even though 50% of lens wearers suffer from symptoms of dry eye and almost 75% will discontinue lens wear at some point due to discomfort (Pritchard et al, 1999), only about 20% report these symptoms to their practitioner. Apparently, many patients think that their eyecare professional will discontinue their contact lens wear if they complain about discomfort.

A good dry eye questionnaire is a great way to assess your patients’ level of dry eye once your staff has broken the ice utilizing an effective script. Some popular ones include the McMonnies & Ho Dry Eye Questionnaire, the Ocular Surface Disease index (OSDI), and the Dry Eye Questionnaire (DEQ). There are also contact lens-related questionnaires based on many of these same test panels.

These questionnaires help you complete the most important diagnostic test of all for dry eye—the case history. No test correlates with the clinical signs and symptoms of dry eye as well as a good case history does. So, you have to get serious about taking good case histories. Sometimes it helps to add those topics that frequently come up in the case history and examination of dry eye patients to your libraries in your EHR system.

Market Your Dry Eye Services

Once you have your system in place, you are ready to perform some area marketing. Remember, it is much less expensive to market to your existing patients. However, with social media, it is relatively inexpensive to reach a much larger area. You can go as far as contacting a media buyer for the opportunity to be interviewed by a television station as a local recognized expert, but we recommend starting smaller.

If you purchase any of the instruments mentioned in this article, make sure that you register on the companies’ websites so that if potential patients look for providers in their area who have that technology, they find you and not some other individual.

Follow-up Fundamentals

After you have started seeing patients who have dry eye, it is helpful to go back and evaluate your progress. Is what you are doing working for both your patients and your practice?

If there is some technology that you didn’t purchase that would help improve the care that you provide to your patients, then perhaps you should make those investments. If adding a dry eye center to your practice is adversely affecting your patient flow, then you need to make changes to correct these problems.

Benefits for All

If you are not capturing these markets in your practice, then you are not taking care of your patients the way you should be. The newer understanding that we now have of the entire dry eye disease and ocular surface disease milieu and the newer technologies available to diagnose and treat these conditions offer the opportunity for a true “win-win” in your practice.

By focusing on dry eye in your practice, your patients will benefit from these much needed services. In addition, you will profit by gaining a reputation within your community as an expert in an increasingly prevalent public health arena, by increasing your interest in a dynamic area of your practice, and by providing more income for your practice. CLS

For references, please visit www.clspectrum.com/references and click on document #224.

	Dr. Newman has been in private practice in Dallas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a Diplomate in the AAO and a consultant to B+L and AMO. Contact him at cdnewman@earthlink.net.
	Dr. Rumpakis is currently president & CEO of Practice Resource Management, Inc., a firm that specializes in providing a full array of consulting, appraisal, and management services for healthcare professionals and industry partners. He is a consultant for or has received speaking honoraria from Alcon, Vistakon, CooperVision, Oasis Medical, Odyssey Medical, Bausch + Lomb, and Essilor.