Review the procedures for success in documentation, coding, and billing.

This month’s issue of Ophthalmic Professional focuses on dry eye disease (DED), so let’s update this important patient issue in terms of documenting, coding, and billing.

Documenting

Dry eye symptoms can be vague in presentation, so it’s important to note all symptoms when performing the history. These notes may help the doctor identify the disorder and properly treat it as well as justify billable testing or treatments ordered.

In taking the history, technicians should specifically ask about surgeries or conditions related to the eyelid, skin, face, and nose, as well as other medical conditions, such as cancer, Sjögren’s syndrome, and allergies. Some of these issues might exacerbate DED, while others might mask it. Finally, note all medications — prescribed or OTC — including supplements.

During the exam, note all findings, positive or negative, either as the technician looking at the eyes or as the scribe for the doctor; doing so helps determine a proper course of treatment.

Remember, there is no perfect correlation between the symptoms and findings with dry eye.

Regarding orders: You can receive a written order (the prior exam), or, if your employer allows it and you are not otherwise restricted by state law, a verbal order.

Do not assume your state permits verbal orders. When the order is verbal to you, record it in the chart for compliance with documentation rules.

Once tests are performed (details below), additional documentation is usually necessary in the medical record. Specifically, all billable tests might generate a number or an image, which should be included in the medical record. Additionally, some tests that have the words “interpretation and report” in their official CPT code descriptor — such as 0330T (tear film imaging) — require the provider to interpret the results, usually via a separate notation, to meet the code documentation and billing requirements. (See a prior OP Coding column from 2016 on Interpretation and Report and what it means to documentation, available at bit.ly/316Coding.)

Coding and billing

Not all diagnostic tests are covered by insurance. They fall into three categories: tests are incidental (part of the exam and not billable to anyone even if there may be small costs to the office such as supplies), paid by insurance, or paid by the patient. It’s important to know which category the test falls into and whether some documentation is expected for insurance coverage or merely for proper documentation even if there is no coverage.

An incidental test can be done by the technician or the provider and no code applies. Here’s a partial list of incidental dry eye tests:

• Schirmer tear testing (type I or II)
• Tear break-up time (TBUT)
• Phenol Red thread
• Rose bengal testing
• Dye disappearance test
• Jones I test
• Tear meniscus height
• Examination at the slit lamp (w/ or w/o dye)
• Blink rate testing
• pH testing (e.g., pH paper)

Other dry eye tests are billable to insurance — but only if medical necessity exists based on symptoms and/or clinical exam findings. As there can be doubt about coverage (not all payers cover the same things or for the same reasons), look for guidance on the payer websites or call directly to inquire.

Some covered tests are:

• Jones II test: The test itself is not billed, but it may involve probing and irrigation of the canalicula; if so, CPT code 68840 is proper.
• Tear osmolarity (TearLab, TearLab): CPT laboratory test 83861 – distributed as “TearLab”*
• Inflammatory tear test for the MMP-9 marker (Inflammadry, Quidel): CPT laboratory test 83516 – distributed as “InflammaDry”*

*Note that these are classified as laboratory testing. Billing for these lab tests requires your office to have a current Clinical Laboratory Improvement Amendment-waiver approval number before billing, the use of modifier QW, and your waiver number on the claim. For example: 83861-QW-RT on the first line and 83861-QW-LT on the second line of the claim. Additionally, both of these tests are payable “per eye” if both are tested. Do not use the bilateral 50, as most payers want each eye’s test on a single line.

Other dry eye tests are not billable to insurance since payers regard them as noncovered. As a result, these tests are paid by patients when they are informed in advance and accept responsibility. Noncovered dry eye tests include tear film imaging, which can be done by a number of instruments on the U.S. market: CPT Category II code - 0330T Tear film imaging, unilateral or bilateral, with interpretation and report.

Importantly, new tests and drops for dry eye come onto the market all the time, so be sure and investigate coverage and coding for those tests as they do, and subsequently receive FDA approval.

Although not a part of the article, don’t forget that meibomian gland disease (MGD) can contribute to dry eyes and providers might also test for that.

Final thoughts

For scribes: be sure all of the above history, exam findings, orders, and test results are present in the medical record, then make sure the doctor comments on all of this in the “Impression and Plan” section. If a test requires an “Interpretation and Report” be sure that is completed as well. This ensures that if, in the future, there are call-backs from patients or their authorized caregivers staff members know what was recommended in the past. Proper documentation also helps if changes in therapy are needed in the future and helps support the level of any potentially billable exam.

As usual, “good coding” to you! OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.