Coding
Coding for Dry Eye and Epiphora
Insurance won’t cover all tear function testing. Familiarity with specific payer policies is vital to receiving payments.
By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA
We encounter dry eyes almost every day in clinic. Some patients return for a re-check, others have new complaints and others are unaware of their condition. Dry eye may be the true culprit when excessive tearing is noted as the primary complaint. In the past we could only test for tear volume issues, but tear quality testing is expanding.
This column covers coding for the more common tear function tests and provide some guidance.
Noting Symptoms
While many symptoms are vague, some are specific. It’s important to note any symptoms. They may be the key to justifying testing or treatments ordered after the doctor sees the patient. Specific questions to ask are related to eyelid dysfunction, facial or nasal surgery, radiation, connective tissue disease, palsies affecting the face, allergies, radiation, and medications. Remember, some medications increase tearing while others have the opposite effect.
Insurance won’t cover all testing. The patient pays for some tests, while other tests are considered “incidental.”
Incidental Tests
Incidental, in this context, means it is not billable to patient or payer. An incidental test (see sidebar) is considered part of the examination and does not matter whether the test is done by the technician or physician. No CPT or HCPCS code, even an unlisted one such as 92499, applies to incidental tests. Payment for incidental tests are included in the payment for the exam service whether an Eye (920xx) or E/M (992xx) code is used – we can’t get any extra reimbursement for doing them.
Incidental Testing Examples: |
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■ Schirmer tear (type I or II)■ Tear Break-up time |
Covered Tests
Other tests are billable to insurance, but only if medical necessity exists based on symptoms or clinical findings. Remember, each payer determines what they cover and under what circumstances, so what one payer allows is not universal. When in doubt, look for guidance in payer documents or call and inquire.
Other tear tests are not billable to most payers—as a result, the patient should pay if they are informed in advance and elect receiving the service.
Written and Verbal Orders
The history and exams are key pieces, but an order is also important to obtain. You can receive a written order, or, if your employer allows it and you are not otherwise restricted by state law, a verbal order can be given to you. Do not assume your state permits verbal orders. If the order is verbal, record it in the chart. The notation to support a verbal order could be as simple as “tear film imaging verbally ordered” and noting your initials as well as the time and date. If the test generates a number or an image, that should be entered onto the chart and saved for retrieval.
Covered Test Examples: |
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■ Jones II if it involves probing and irrigation of the canalicula) ■ If so, CPT code 68840 is proper ■ Tear Osmolarity (CPT laboratory test 83861) ■ Requires a special lab consideration (known as a Clinical Laboratory Improvement Amendment (CLIA) waiver to provide the ability to bill for it ■ Billing once a CLIA-waiver is present requires modifier QW ■ Payable per eye |
Closing the Loop
With tear function testing, make sure all the tests done, or ordered for a future date, make it into the Impression and Plan. Doing so proves they were considered and help support the level of exam service.
Coverage for tear function testing is variable and it’s important to know if payment exists and from whom it may be obtained. Don’t let a bill for something get sent merely because it was paid in the past. Payment policies do change.
As usual, “good coding” to all of you! OP
Paul Larson, MBA, MMSc, COMT, COE, CPC, CPMA, is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta. |