Medical Model

Enhance Dry Eye Treatment to Better Serve Patients

By Jeanmarie Davis, OD

Expanding your treatment of dry eye can help you provide your patients with improved vision, while opening up a new area ofgrowth for your practice.

ROB Bottom Line

Jeanmarie Davis, OD, of Hialeah, Fla.,says dry eye treatment is essential to both her patients and her practice.

Dry Eye
80 percent of the 20 to 30 patients seen daily

Fee
Medicare allowable-
$43.85-$74.85 for at least four follow-up visits per year

$328-$394 for punctal plugs, including additional necessary follow-up visits

Each Dry Eye Patient
Up to $400 to $700 annually

Calculate Number of Dry Eye Patients
Chances are, your practice has many patients who have undiagnosed dry eye. With contributing factors such as age, hormonal changes, systemic illness and the after effects of Lasik surgery, it is more common than you think. Some 80 percent of the average 20 to 30 patients I see per dayhave some form of dry eye, ranging from asymptomatic and mild to severe and impacting quality of life. The demographics of my south Floridapatient base create the perfect storm for dry eye–a high percentage of elderly persons (many of whom have diseases thatproduce dry eye)and Hispanics (who, some studies suggest, experience higher levels of dry eye than the rest of the population). Dry eye in my practice is so prevalent, in fact, that each week I devote a full day to offering a dry eye clinic in which I see only dry eye patients.

DiagnoseDuring Check-Ups
Sometimes patientscome in specifically complaining of dry eye, but more often, their symptomsare revealed during a routine check-up through an open question such as: “How do your eyes feel?Are you experiencing any discomfort, or anything that is negatively impacting your vision? Do your eyes get red, burn or tear?” In response, patientsoften say their eyes always feel like there is something in them like sand or an eyelash, yet when they check there is nothing in their eyes. They mightsay their eyes feel irritated and are tearing more than they used to, or they maysay they have been experiencing a feeling of pressure behind their eyes that leads to headaches. All of these symptoms are classic tell-tale signs of dry eye.

Business Opportunity in Follow-up Care
After the typical diagnosis in a routine check-up, the dry eye patienttypically returnsto the office formultiple follow-up visits, each with a fee of $74.85 (using the code 99213). The national average is $59.73, but it can be as low as $43.18. Thereimbursement will vary from state to state.The first follow-up visit is tofurther assess and classify the diagnosisand the severity and initiate treatment.Tests conductedinclude, for instance, Schirmer’s Test,which gauges whether there is sufficient tear production in the eyes; expressing and observingthe eye lids; andextracting andevaluating themeibum. Confirming the diagnosis with specific testingis required by many insurance companies to receive reimbursement for treating dry eye.

The second follow-up visit typically occurs two to four weeks later to assess progress. You want to see how compliant the patient is on the regimen, determine subjective improvement by asking the patient how much relief they feel,and then objectively assessing their eyes. Also check for adverse side effects, such as the burning and stinging sensation from a medication likeRestasis, or a dangerous increase inocular pressure which other medications can cause.

Offer Punctal Plugs
For at least20 percent of my patients, the initial therapy prescribedis not enough. For those patients, I often recommend punctal plugs, a procedure in which biocompatible devices are inserted into thepuncta to block the excessive drainage that contributes to dry eye. This procedure usually requires multiple office visits in itself. During the first visit, temporary collagen plugs are insertedthat will dissolve on their own within a few days. Two weeks later,the patient is re-examined andinterviewed todetermine whether inserting permanent plugs would be worthwhile. If it would be beneficial to the patient, the silicone plugs are inserted the same day. Patients are scheduled to return for follow-up in three months.

Insurance reimbursement for punctal plugs is significant. On average, insurance typically allows medical reimbursement of$131.35 with 100 percent reimbursement for the first plug and 50 percent reimbursement for thesecond. The entire course of punctal plugs is about $328-394, plus follow-up visit fees.(ROB EDITORS: Two points on reimbursement: (1) Always bill 100 percentof your fee to the third party.Let them decrease the fee of the plugs beyond the first. (2) To receive third-party reimbursement for punctal plugs, your documentation must show that you tried other treatments that failed.) The entire course of punctal plugs is about $400, plus follow-up visit fees.Punctal plug procedures also are cost-effective in that they require no more than about10 minutes of chair time.

Whatever medicine or procedure is prescribed, all dry eye patients are seenevery three months to assess their eyes and comfort level. With all of these follow-up visits (and even more so if the patient requires punctal plugs), each dry eye patient brings up to$400 to $700 annually.

Talk the Talk

Manage Dry Eye Patient Compliance and Expectations

Effective treatment of dry eye requires patient education. When the patient is diagnosed, and during each follow-up visit, I remind them of key points. Here is an example of what I would say to a dry eye patient:

“I want to remind you to be patient with your treatment. Dry eye is a chronic disease, and there is no cure, but by following the therapy I have prescribedon a permanent basisyou will be able to reduce the symptoms to the point that you may no longer notice them at all.

“I also want to make you aware of the importance of keeping follow-up appointments. You may experience an increase in eye pressure as a side effect of the medication, which can pose a danger to your vision. I need to monitor your eyes to make sure I take you off the medication if that happens before damage to your vision is done.

“My goal is for your eyes to be as healthy as possible, and for you to be as comfortable as possible. If you stick to the regimen I have prescribed, and come back for follow-up visits for me to monitor your eyes, we can reach that goal together.”

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Managing Medical Eyecare
Jeanmarie Davis, OD,is head, technical, Global Performance Development at Alcon.To contact her: drdavis2020@yahoo.com

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