Keeping our patients’ ocular surface healthy and comfortable sounds simple, but in fact can be very challenging. The ocular surface is involved in most things that we do: contact lenses, refractive care, glaucoma, cataracts and refractive surgery. 

Though ocular surface disease (OSD) itself can be complicated, coding for ocular surface diagnostic care and ongoing management is very simple and straightforward. It generally consists of a combination of office visits and specific clinical tests. Many of the traditional diagnostic tests performed for “dry eye”—such as Schirmer, phenol red thread, tear film break-up time and tear prism analysis—are usually considered to be part of the office visit and not separately identified by the CPT or HCPCS with their own codes.  

However, some recent technologies—separately identified as a new CLIA-waived procedure and a Level III HCPCS code—can be coded in addition to the office visit:

• 83516. The currently available product is InflammaDry (Rapid Pathogen Screening), and the test is defined by CPT as: “Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method,” is now a CLIA-waived, in-office test. (So, for each procedure performed, use the modifier –QW, which marks it as a CLIA-waived test.) It must be done in a practice that has a clinical lab designation and with a physician who has been registered as a clinical lab director. The current national reimbursement amount for this lab test is $15.52 per eye.

• 0330T. “Tear film imaging, unilateral or bilateral, with interpretation and report.” This code for tear film interferometry—marketed as LipiView (TearScience)—is a Level III HCPCS code, which means it is used to track utilization of new technology and needs to be reported to the carrier. As such, there is no reimbursement associated with this code, and the patient generally pays for it. Because 0330T now defines this service more explicitly, coordinating rules require that this code must be used instead of CPT code 92285 (anterior segment photography).

CPT for OSD is A-OK

When coding the office visit, remember that there is no difference between dry eye, cataracts or even a retinal problem in the sense that they are all recognized disease processes that require proper anatomical assessment of structure and function. So, whenever you perform medical eye services, the first area of the medical record you should assess is the chief complaint (CC). The CC must reflect the reason for the visit; it comes either from the patient as a complaint or symptoms of an eye disease or injury, or from your directive to return to the office for a very specific reason. 

Determining the specific CPT code to use is fairly simple. Of the 920XX codes, most likely only the intermediate codes, 92002 or 92012, would be appropriate; however, keep in mind that if you use a 92012, the patient must present with a new condition or an existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis. In other words, as most patients in this scenario are established patients, and unless the patient presents with a new condition or additional complications relating to dry eye not previously noted, 92012 is not appropriate to use because the specific definition of this code has not been met. 

That leaves the 992XX codes. The beauty of the 992XX codes is that they are structure driven. You, as the physician, determine the clinically relevant and pertinent anatomical areas to examine and evaluate. The level of history and medical decision-making are fairly specific and limited in most cases. For OSD, the codes used in the 992XX system are 99201, 99202, 99212 and 99213. Always code each patient encounter by the individual case presentation and the individual patient you’re examining and treating.

Managing the ocular surface is professionally rewarding, a lifesaver for your patients, and a tremendous practice builder. Keep these clinical skills and coding guidelines top of mind and all areas of your practice will benefit.

Please send your questions to [email protected].