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Ophthalmologists know that a very large number of patients in general practice, and in many subspecialty practices, present with eye symptoms that are too dry or too wet. These common situations trigger coding issues that must be understood in order to ensure proper compensation for care of this sizable patient group.
Sometimes, symptoms and signs of dry eyes and wet eyes coexist. This is the case in reflex epiphora, in which an underlying dry eye condition triggers reflex tearing. Another scenario in which symptoms of both conditions are present is that of paralytic ectropion. The eye dries out due to exposure, but epiphora also exists due to displacement of the lower punctum away from the tear film. These presentations add to the complexity of coding.
Appropriate coding for visits, tests, and procedures in these patients requires familiarity with the relevant diagnosis and service codes. Also, basic principles of evaluation and management coding and use of modifiers are important.
The chief complaint takes on particular relevance in patients with dry eyes or wet eyes. These patients often present with various complaints. Some of these complaints trigger a lengthy differential diagnosis that must be worked through in order to determine appropriate treatment. For example, a chief complaint of significant ocular pain should probably be described as such. This seems prudent even if the quality of the pain is dry and scratchy.
The next step in documentation is the history of present illness. This is a key component of coding for evaluation and management (E/M) services. As with all E/M visits, four of the following elements are necessary (but not sufficient) to reach the requirements of a "comprehensive" history: location, quality, duration, timing, severity, modifying factors, context, and associated signs and symptoms. (Another way to fulfill the requirements partially for a comprehensive history is through documentation of the status of three chronic conditions.)
Examination findings should be carefully noted. Positive findings carry particular impact when it comes to determining the final level of service. These findings should be documented: decreased blink, conjunctival hyperemia, corneal epitheliopathy, punctal stenosis, punctal eversion, frank ectropion. The following are also helpful to record: rapid tear breakup time; decreased Schirmer's test levels; and staining with rose bengal, lissamine green, or fluorescein.
Many practitioners are familiar with the ICD-9-CM diagnoses 375.15, Tear film insufficiency, unspecified; and 375.20, Epiphora, unspecified. However, many other diagnoses may apply to these patients and should be documented when present. They include those in the 370 series, Keratitis (including superficial keratitis, punctate keratitis, and keratoconjunctivitis sicca) and in the 374.1 series, Ectropion.
Commonly overlooked diagnoses that may be present and may add to the significance of the encounter include 379.91, Pain in or around eye; 379.93, Redness or discharge of eye; 375.51, Eversion of lacrimal punctum, and 375.52, Stenosis of lacrimal punctum.
In general, conditions that involve multiple systems merit consideration of higher levels of service. Therefore, diagnoses such as 710.2, Sicca syndrome, or 714.0, Rheumatoid arthritis should be noted when applicable.
Testing is commonly indicated in these patients. Not all tests are compensable, however. For example, basic tear secretion and Schirmer testing are included as components of an office visit. Historically, CPT 95060, Ophthalmic Mucous Membrane Tests, was used by some practitioners to report Schirmer testing, but this was not appropriate usage of this code.
Lacrimal probing is, from a clinical standpoint, often diagnostic in nature. Lacrimal services, however, are listed in the Eye Surgery section of CPT rather than with other diagnostic services (such as gonioscopy or fluorescein angiography) in the Medicine section.