Medical Model

Dry Eye Patients: Serve a Growing Population

By Craig Tisch, OD, and Dori Wolf, OD

SYNOPSIS

Comprehensive dry eye services are a must with our aging population. Ready your practice to serve the increasing numbers of dry eye patients, and take advantage of a practice-building opportunity.

ACTION POINTS

EDUCATE & HELP UNDERSERVED PATIENTS. Let patients know you can help them.

INVEST IN NECESSARY INSTRUMENTATION. A slit lamp is essential, along with a corneal topographer and a camera for external ocular photography.

CODE EFFECTIVELY.Initial and subsequent visits code differently. Get it right so you don’t leave money behind.

Roughly 15-20 percent of all the patients that we examine in our New York City practice have complaints of dry eye. This includes contact lens and non-contact lens patients. These complaints can range in severity from very mild (silent sufferers) to extremely painful and severe with vision loss.

The practice of proper dry eye management is a profit builder namely because there is minimal cost of goods involved and patients typically return to the office at least a few times annually. The difficult part of management is that once patients begin to notice their symptoms improving, they feel less inclined to follow up. However, building patient rapport and increasing patient confidence serves to not only increase patient loyalty, but also to increase patient referrals. And, as we all know, satisfied patients coupled with patient referrals drive practice growth.

Potential ROI

Follow-up visits per-patient for dry eye and Restasis management can produce $200-400 per year depending on the insurance coverage. Punctal plugs also are source of practice income and can generate anywhere from $200-300 per year. Therefore, each dry eye patient can generate approximately $400-800 per year. Multiply that figure by the number of dry eye patients you see per year and it becomes clear that the treatment of dry eye is a profitable aspect of your practice.

The corneal topographer, a key instrument, which we outline the use of later in the article, costs between $12,000 and $15,000, on average. The newer instruments actually offer dry eye analysis software, as well. For dry eye purposes we can bill insurance between $20-$40 per patient per test. Self-pay patients generally pay an additional $40 above the usual comprehensive eye exam fees.

Therefore, if we perform 10 tests per week on dry eye patients we generate enough income to pay the lease on the instrument. And this does not include the income we generate outside of dry eye patients for difficult contact lens fittings and various corneal disease. A corneal topographer offers a great source of income to any dry eye practice.

HELP UNDER-SERVED PATIENTS

Many new patients to our practice who present with complaints of dry eye often report they have never been formally treated or managed for the condition. Most report being given artificial tears and told to return for further evaluations if the complaints continue. Patients often feel neglected and frustrated by the lack of advice from their prior eye doctor and are often excited by the thought of treatment options beyond artificial tears.

INVEST IN NECESSARY INSTRUMENTATION: 3 EASY & EFFECTIVE TOOLS

Slit Lamp, Camera for External Ocular Photography and Corneal Topographer

A careful slit lamp evaluation with fluorescein is crucial for evaluation of a patient you suspect to have dry eye disease. The fluorescein evaluation can uncover corneal changes that might otherwise not be detected on slit lamp examination alone. Photo documentation of any corneal defects is extremely helpful for creating a baseline for a particular defect found on the cornea.

Corneal topography is another useful tool when evaluating patients for dry eye. In many cases the irregularity of the cornea can be measured and followed as the condition improves. It is also a great way to educate the patient on what is happening to the corneal surface and track for improvements as your treatment progresses. In most cases topography and anterior segment imaging is reimbursable by insurance. Just be sure to check with the insurance carrier on how frequently these tests can be performed and billed.

These are three easy and effective tools for evaluating and managing many dry eye patients in our practices. We are constantly looking to our colleagues that research dry eye for new ideas and perspective on evaluating and treating this disease.

PATIENTS VISIT MULTIPLE TIMES ANNUALLY

We like to see our dry eye patients about three to four times a year for proper management. At the initial visit, an assessment is made of their condition. The exam consists of, but is not limited to, a thorough patient history, discussion of medications taken, fluorescein evaluation, assessment of other contributory factors such as lid margin disease, TBUT (Tear Break-Up Time) and assessment of staining and tear prism.

After extensive discussion between doctor and patient, a treatment plan is prescribed to target the severity of the patient’s dry eye. We typically like to see our patients about a month following the initial visit to follow up and determine if the patient notices improvement of the condition. At that visit, further treatment may be advised. We encourage the patient to return for evaluation and monitor the condition every month for the first and third months following initial treatment.

NOTE KEY DRY EYE BILLING CODES

When treating “dry eye patients,” it is necessary to use the appropriate diagnosis and procedure codes. We use the 920XX for our initial visit and comprehensive examination. Subsequent visits and management are coded according to the issues being treated and billed with one of the 992XX codes. When treating patients with dry eye with punctual plugs, be sure to bill for the visit, procedure and supplies. Many of the punctual plug manufacturers have the local coding information that can assist in getting started.

EDUCATE PATIENTS

We explain to our dry eye patients that they have a chronic condition. We discuss with patients that while their condition cannot be cured, there are treatments that can keep them comfortable if they are compliant. We educate our patients that dry eye can be a result of a number or combination of external and internal factors. For instance, in the winter in New York City, we notice an increase in dry eye issues and complaints. We educate our patients that artificial heating, in addition to cold, dry air conditions, can exacerbate their symptoms.

Patients sometimes are confused about the diagnosis of dry eye when their main complaint often is an excess of tears. We explain that dry eye is not diagnosed on the basis of quantity of tears, but on the quality of tears. We try to create an image in our patients’ minds of the eye sending a message to the brain when they become very dry. As a result, the brain automatically produces more tears. However, the new tears produced lack the lubricating qualities of the original tears, so they actually create more irritation. In order to avoid the eye from sending the dry signal to the brain, we try to hone in on the importance of keeping the eyes moist through every means possible including lubricating tears and gels, Restasis and punctal plugs.

GUIDE CL PATIENTS

Many patients have stopped wearing contact lenses and some are looking for advice and suggestions. We explain the importance of treating the ocular surface, resolving the symptoms, and then looking to some of the new technologies in contact lenses that have become available. Many patients experience symptoms that we think are dry eye, when, in reality, they are a result of a lens that is not best suited for the patient’s eye.

Daily replacement lenses are the most promising choice for many of these patients as it provides them with a fresh, new lens every day. There are a number of new lenses on the market including Acuvue Trueyes and Alcon’s Dailies Total 1 that have both proven very successful for our patients with a history of contact lens-related dry eyes. The water gradient technology in Dailies Total 1 has been an extremely successful lens for these patients in our office. Patients feel that the added moisture in the lens resolves many of their complaints, and they often report not even being aware of the contact lens.

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Craig Tisch, OD, is a co-owner of Miles & Tisch Eyecare in New York City. To contact him: drtisch@yahoo

Dori Wolf, OD, is an associate with Miles & Tisch Eyecare in New York City. To contact her: wdori@hotmail.com

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