Tear Osmolarity Testing
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This policy defines medical necessity, documentation, coding, and utilization requirements for tear osmolarity testing (CPT/HCPCS code 83861) for management of ocular surface disease/dry eye and applies to providers requesting coverage from Clear Health Alliance/Avēsis.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Coverage Criteria
Covered when ALL of the following are met:
Coverage for tear osmolarity testing requires use of an appropriate diagnosis from the plan's allowed indications. State-specific variations and Health Plan-specific "Indications and Limitations of Coverage" may apply and should be followed when submitting claims or prior authorization requests. The policy applies to testing billed with CPT/HCPCS code 83861 and is intended to establish medical necessity when signs or symptoms of dry eye or ocular surface disease are present and properly documented.
Services will be denied as not reasonable and necessary if the documentation requirements in this policy are not met. All coverage criteria must be clearly and legibly documented in the medical record, including physician signature(s); clinic/progress notes supporting medical necessity; the sign or symptom prompting the test; explicit identification of "tear osmolarity" with the numerical result and indication of normal/abnormal; a dated test interpretation note with findings, progression/stability, diagnosis and physician signature; and documentation of medical action taken as a result of the test. The ordering physician must be the managing physician of the patient. Avēsis may request clinical records to justify the diagnosis and the necessity of the procedure; failure to provide adequate records will result in denial.
Coding
| 83861 | Tear osmolarity testing (applicable CPT/HCPCS code as referenced in policy) |
| RT | Modifier for right eye |
| LT | Modifier for left eye |
| H04.121 - H04.129 | Dry eye syndrome of lacrimal gland |
| H11.141 - H11.149 | Conjunctival xerosis |
| H16.101 - H16.109 | Unspecified superficial keratitis |
| H16.121 - H16.129 | Filamentary keratitis |
| H16.141 - H16.149 | Punctate keratitis |
| H16.211 - H16.219 | Exposure keratoconjunctivitis |
| H16.231 - H16.239 | Neurotrophic keratoconjunctivitis |
| H18.831 - H18.839 | Recurrent erosion of cornea |
| M35.00 | Sicca syndrome, unspecified |
| M35.01 | Sicca syndrome with keratoconjunctivitis |
Provider Actions and Documentation
Prior authorization may be required
Prior authorization may be required for CPT/HCPCS code 83861; for any diagnosis not listed in the policy, supply proper documentation with the prior authorization request for Avēsis review and determination of medical necessity.
Provider responsibilities for ordering and documentation
Ensure the ordering and documentation requirements below are met: the ordering physician must be the managing physician, testing must be documented as 'tear osmolarity' with numerical result and normal/abnormal indication, physician signature and test interpretation must be present, and clinical findings and the sign/symptom prompting the test must be recorded.
Required documentation (legible, signed, and complete)
All coverage criteria must be clearly and legibly documented in the patient’s medical record and include physician signature on chart/procedure/orders, clinic/progress notes supporting medical necessity, the sign or symptom prompting the test, explicit identification of 'tear osmolarity' with numerical result and normal/abnormal indication, and a test interpretation note with date, findings, progression/stability, diagnosis, and physician signature.
Ordering physician must be managing physician and document treatment actions
The ordering physician must also be the managing physician of the patient’s medical care; document any medical action taken as a result of the test with reference to the test results in the treatment plan.
Denial risk if documentation does not meet criteria
Services will be denied as not reasonable and necessary when the documentation does not meet the policy criteria or does not establish medical necessity; Avēsis may request clinical records to justify the diagnosis and necessity of the procedure.
Background
Tear osmolarity testing is a microfluidic analysis performed with an integrated collection and analysis device to evaluate ocular surface disease associated with dry eye. The test yields a numerical osmolarity result that must be recorded in the medical record and used to guide management and monitoring of the diagnosed condition.
Definitions
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