From Steps to Strategy: Making DEWS III Work in the Real World (Without Getting Burned on Billing)

From Steps to Strategy: Making DEWS III Work in the Real World (Without Getting Burned on Billing)

By Dr. Cheryl Chapman, OD, FAAO, IACMM, FIAOMC, Diplomate ABO — Dry Eye Expert & Co-Founder of Peeq Pro

Let’s start with the obvious: everyone with eyelids should be cleaning them — every single day.

At Peeq Pro, we call it “peeqing” your lids, and it’s the foundation of every healthy ocular surface. When the lid margins stay clean and the meibum flows, you’re preventing half of the problems that end up in your chair. It’s the baseline for anyone with eyes.

Of course, the classics still matter. Omega-3 supplements, warm compresses, and consistent lid hygiene are still the pillars of good dry-eye management. Those recommendations go all the way back to DEWS II — and they still work beautifully.

But what DEWS III adds isn’t a replacement — it’s a reframing. It’s about how we think through dry eye today.

From a Ladder to a Map

DEWS II gave us that comforting “staircase” approach: start simple, escalate later. Step 1, artificial tears and hygiene. Step 2, maybe a short steroid pulse. Step 3, advanced drops or devices.

But the reality? Patients don’t live in steps.

Some walk in with obvious inflammation from day one—red conjunctiva, punctate staining, angry lid margins — and they get sent home with another bottle of tears. Six weeks later, they’re worse, not better.

DEWS III invites us to toss out the rigid staircase and replace it with a diagnosis-driven map. Instead of asking, “What step am I on?”, we ask, “What’s driving this disease right now?”
Is it inflammation? Meibomian obstruction? Aqueous deficiency? Neural dysregulation?

Then we treat that driver directly — immediately and intentionally.

The Inflammation Example: Pulse Early, Protect Long-Term

Inflammation is the common denominator across nearly every dry-eye subtype —aqueous-deficient, evaporative, mixed, or neuropathic.

DEWS III gives you permission (and evidence) to act on it early. Start with a soft steroid pulse — loteprednol or fluorometholone are my go-tos—to calm that inflammatory storm and break the irritation cycle. Then, transition to long-term control with calcineurin inhibitors (like cyclosporine A) or T-cell blockers (like lifitegrast).

Meanwhile, the foundation doesn’t change: lid hygiene, Omega-3s, hydration, and environmental optimization all continue alongside.

It’s not “Step 1 or Step 2.” It’s “What’s active today—and how can I quiet it down?”

The Real-World Barrier: Billing and Coding

Here’s where the clinical meets the bureaucratic.

As covered in Peeq Pro’s “Billing & Coding Dry Eye Like a Pro,” even the best care plan can backfire if you bill it wrong. A comprehensive exam (usually billed under a vision plan) isn’t the same as a medical management visit.

If you diagnose, educate, and prescribe under that comprehensive exam, you’re setting yourself up for a denied claim — or worse, an audit.

So how do we practice the DEWS III integrated model without tripping over billing rules?

You split the process, not the care.

Step One: The Comprehensive Exam

At this visit, you:

  • Identify the signs and symptoms: tear breakup time, staining, gland expression, osmolarity, etc.

  • Educate the patient on foundational care — daily lid hygiene (“peeq your lids”), warm compresses, Omega-3s, hydration, and screen-time habits.

  • Document everything clearly.

Then, bill this as a comprehensive eye exam, not as medical management.
This keeps your chart clean and compliant while setting the stage for your next move.

Step Two: The Ocular Surface Disease Evaluation (OSDE)

After 4–6 weeks of consistent self-care, reassess. If inflammation or signs persist, now you have the clinical and charted justification for medical treatment.

That’s when you add:

  • Prescription anti-inflammatories (steroid pulse, CsA, lifitegrast)

  • Objective testing like MMP-9, osmolarity, or meibography

  • And bill appropriately — typically a 99213 or 99214, depending on complexity

This sequence maintains continuity of care while staying fully compliant.
Or as Dr. Wolfe aptly put it, “identify, document, and separate.”

Why This Works

This two-stage model strikes the perfect balance:

Clinically: You’re treating in alignment with DEWS III—no artificial delay in managing inflammation

Financially: You’re protecting your practice by documenting medical necessity and proper sequencing.

You’re not withholding treatment; you’re simply creating a paper trail insurance understands. And yes, sometimes that means you shorten the conservative-care window to get symptomatic patients comfortable faster — but it’s still within ethical, evidence-based care.

The New Standard of Care

DEWS III doesn’t rewrite what we do — it validates it. It acknowledges what we’ve known for years: dry eye is multifactorial, dynamic, and deeply personal.

Patients don’t want a “step plan.” They want a solution that meets them where they are today.

Our job is to blend clinical intuition with practical structure — start with strong lid hygiene and self-care, identify inflammation early, and document thoughtfully.

Split your billing, not your care logic. Follow the map, not the ladder.

When you align DEWS III’s clinical insight with smart documentation, you elevate your dry-eye care clinically, financially, and ethically.

You treat smarter, faster, and without getting burned in the process.


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