Dry eye disease (DED) affects millions of patients worldwide and is a common reason to seek eye care. A variety of DED therapies are available, but because DED varies in severity between patients no single therapy works for everyone. Evaluation and management of DED relying on evidence-based medicine is the best approach.

Q. What guidelines exist regarding treatment?

A. DED is amenable to step therapy generally starting with artificial tears and lid hygiene. The definitive source for appropriate evaluation and management of dry eyes is the Tear Film and Ocular Surface Society (TFOS) publication of the 2017 International Dry Eye Workshop (DEWS) II.¹ It provides clear guidelines for the staged management of DED.

DEWS II also is the basis for the AAO’s Dry Eye Syndrome Preferred Practice Pattern.²

Q. What does Medicare say about treatment of DED?

A. Medicare and other payers reimburse for medically necessary services for the diagnosis, treatment or management of disease, injury and abnormalities. The Medicare law says, “… no payment may be made under part A or part B for any expenses incurred for items and services … not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”³

The phrase “reasonable and necessary” is further defined and clarified in the Medicare Program Integrity Manual, Chapter 13 §13.5.4.⁴ It specifies “appropriate care” as care that “meets, but does not exceed, the patient’s medical need.” Step therapy, as outlined in DEWS II, meets the patient’s need because of the graduated treatment.

Q. We understand use of amniotic membrane therapy is heavily audited. Where does it come into the plan?

A. Within the DEWS II therapeutic hierarchy, amniotic membrane is recommended only after Steps 1-3 have been shown to be inadequate, contraindicated or unavailable. Generally, amniotic membrane is only used in severe dry eyes, such as those associated with Sjogren’s syndrome. Less intensive and less expensive therapy is selected first.

Medicare utilization of temporary amniotic membrane (65778) is minimal primarily because it is reserved for the most severe cases. Within the Medicare program, the usage of this code is 0.11% of all eye exams in this population. This means an amniotic membrane is placed on these patients 11 times per 10,000 eye exams. A higher utilization rate may occur in a practice specializing in severe corneal disease, but if you do not have such a practice, higher utilization rates could garner unwanted attention from payers.

Q. Do payers typically reject claims for treatments that don’t adhere strictly to the steps outlined in DEWS II?

A. During our work with physicians, we found some who skip steps in the DEWS II hierarchy for DED therapy and have been subject to audits from various payers. Here are some examples:

1. Physician placed amniotic tissue as a first-line treatment for DED before treating with any other therapy such as artificial tears, ointments, anti-inflammatory agents, punctal occlusion or autologous serum.
2. Physician performed punctal occlusion at a new patient exam before trying artificial tears.
3. Physician performed punctal occlusion of four puncta in one session without considering if two puncta would suffice to treat DED.

These examples suggest a desire for higher reimbursement for treating DED using an aggressive approach. Ultimately, this was unsuccessful because the payer recaptured the payments for services that were deemed not medically necessary.

The DEWS II and AAO guidelines represent the gold standard for professional care for DED. For reimbursement purposes, these guidelines also define reasonable care. A too-aggressive approach that does not adhere to step therapy may lead to post payment review and repayment of funds to the payer. OM

REFERENCES

1. Craig JP, Nelson JD, Belmonte C, et al. TFOS DEWS II Report. Ocul Surf. 2017 Jul;15:276-283. https://tinyurl.com/yckk2b39 . Accessed March 22, 2023.
2. Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern. Ophthalmology. 2019 Jan;126:p286-334. https://pubmed.ncbi.nlm.nih.gov/30366798 . Accessed March 22, 2023.
3. 42 USC 1395y Exclusions from Coverage and Medicare as a Secondary Payer. https://www.ssa.gov/OP_Home/ssact/title18/1862.htm . Accessed March 22, 2023.
4. Medicare Program Integrity Manual, Chapter 13 §13.5.4. https://tinyurl.com/2e62nwcd . Accessed March 22, 2023.

 

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .