Struggling With Reimbursements for In-Office MGD Procedures?

Dry eye disease (DED) is primarily characterized by a dysfunction of the tear film, which is divided into three layers: lipid, aqueous, and mucin. Composing the lipid layer are the meibomian glands, and meibomian gland dysfunction (MGD) is a main contributor to DED, given the meibomian glands’ role in tear film homeostasis.¹ Behind the slit lamp, MGD can be seen in the form of saponification, “foamy-frothy” tears, or upon direct expression of the meibomian glands. Healthy glands should secrete a clear meibum, while various forms of viscosity can be seen in cases of MGD, depending on severity.

Obtaining insurance coverage for therapies to treat MGD through any medical insurance company is challenging, and oftentimes patients are left with only cash-pay options. This article reviews some of the available tools for treating DED, the cost to patients for their use, and relevant CPT codes associated with each.

THE BREAKDOWN: COST & CODING

Imaging

Slit-lamp anterior segment photography is a great patient education tool. The CPT code 92285, external ocular photography with interpretation (eg, close-up photography, slit-lamp photography, gonio-photography), can be used for this service. The 2018 Medicare Physician Fee Schedule allowable for 92285 is $21.24.² For tear film imaging, CPT instructs providers to use the code 0330T, while 0507T is the appropriate code for near-infrared light meibography.²

Although there are no limitations for repeat imaging, valid documentation is required with the reason for the additional images. Our office will typically assign an Advance Beneficiary Notice to images and procedures because reimbursements from third-party carriers are unreliable.³

Exfoliating Therapy

BlephEx (Alcon) is a quick and easy procedure performed in-office that uses mechanical debridement to remove debris and bacterial biofilm from eyelids. Although BlephEx does not have its own CPT code, code 92499, which is for reporting ophthalmologic procedures that do not have a specific code, can be used in these cases.⁴ BlephEx is relatively inexpensive for patients. It typically costs between $150 to $250 per treatment and is recommended every 4 to 6 months.⁵ BlephEx is well-tolerated in patients of all ages and skin types.⁶

Heat Therapy

The LipiFlow Thermal Pulsation System (Johnson & Johnson Vision Care) includes bilateral thermal pulsation therapy with coinciding lid massage that lasts 12 minutes. Treatment is usually repeated yearly and costs between $750 to $1,500 per session.⁷ Category 3 or “T” codes 0207T and 0563T were used for thermal lid treatments, such as LipiFlow and the TearCare System (Sight Sciences), but the National Government Services (NGS) recently removed the use of these codes for both procedures.⁸

TearCare provides localized thermal therapy using proprietary SmartLids technology, in which multiple temperature sensors communicate with the companion SmartHub 240 times per second to ensure heat is closely controlled and consistent throughout the procedure,⁹ which takes about 15 minutes and requires manual expression of the meibomian glands afterward. It is recommended about every 6 months¹⁰ and typically costs the patient between $500 and $700 for each session.¹¹

The Systane iLux MGD Thermal Pulsation System (Alcon) is another thermal therapy option that uses an LED heat source to warm the lids to between 100°F and 108°F and turns off once the target lid temperature is reached. Most optometry offices charge patients around the same cost as TearCare for this thermal therapy.¹¹

Intense Pulsed Light Therapy

The root cause of DED is cyclical inflammation,¹² and with intense pulsed light (IPL) therapy, the light from the laser is selectively absorbed by telangiectatic blood vessels, causing them to shrink. This effect decreases the inflammatory load and number of cytokines around the eye. IPL can also rid the lids of Demodex, which infiltrate the meibomian glands and cause dysfunction.¹³

Most IPL therapies cost about $400 per treatment and require at least three treatment sessions to experience results.¹¹ OptiLight (Lumenis) does not have its own CPT code, but many offices use 17999, which is for unlisted procedures for skin, mucous membrane, and subcutaneous tissue.⁴ Eye-Light (Topcon) combines IPL and low-level light therapy (LLLT) to enhance cellular processes through mitochondrial cytochrome c oxidase modulation. No gel is required, and LLLT is considered to have a favorable safety factor on application to the upper lids. CPT code 17999 can be used for this IPL treatment as well. Equinox Low Level Light Therapy (Marco) is another option. Treatment takes around 15 minutes and uses photobiomodulation technology that stimulates the production of adenosine triphosphate.^14,15

Meibomian Probing

Intraductal meibomian probing with the Maskin 2 mm MGI Probe (Katena) is not associated with a specific code, but 67999 would be an appropriate nonreimbursement medical code to use with this procedure.¹⁶ Probing activates stem cells, which initiates proliferation and debrides the ductal epithelium, leading to better outflow and growth of meibomian glands.¹⁷

The MiBo Thermoflo (MiBo Medical Group) device features a reusable probe that delivers thermoelectric heat for 8 to 12 minutes during each of three treatments spaced 2 weeks apart. Each treatment session with MiBo Thermoflo costs between $100 and $400.¹¹

WHERE THERE’S A WILL …

Patients around the world experience symptoms of MGD, and we have an increasing number of tools available to us with which to offer them relief. However, providers do not seem to be pushing insurance companies for coverage because reimbursements aren’t always enough to cover the cost of the devices themselves. Remind patients that they can use their flexible spending accounts to cover treatment and consider offering payment plans to help cover necessary procedures.

Diagnosing MGD early is key in preventing patients from even needing treatment with the aggressive therapies listed above. Do everyone a favor and be sure to educate your patients on proper lid hygiene, blink rates, screen time, and the use of dietary supplements, which can also have a significant effect on long-term outcomes.

Editor’s note: The coding and reimbursement information in this article was reviewed by Thomas R. Cheezum, OD, CPC, COPC, of Tidewater Optometric Consulting Services (optometricconsulting.com).