The “Dark Cockpit” Lesson for Dry Eye Clinics: How to Triage Care & Bill Correctly When Time Is Tight

By Chris Wolfe, OD, FAAO, Dipl. ABO

A few nights ago, I had one of those flights that forces your brain into simplicity.

Short trip. Night. Everything normal—until it wasn’t. The radios went to static, the panel flickered, and then I noticed the amps at zero. That’s the moment you stop thinking in “full workflow” mode and start thinking in “what keeps me safe in the next 10 minutes.”

I landed with only strobes and runway lights, and I remember a very specific pressure: people were asking for helpful details, but answering them didn’t change the outcome. What changed the outcome was staying focused on the next small, critical step.

I’ve been thinking about that constantly in clinic—especially with dry eye.

Because dry eye visits are where we’re most tempted to equate great care with doing the whole workup every time… and that mindset can quietly break both patient flow and clean billing.

The dry eye version of “fly the plane first”

We all love the full diagnostic baseline:

• symptom scoring / history

• TBUT, staining, lids/meibomian evaluation

• tear meniscus height

• osmolarity

• inflammatory testing (e.g., MMP-9)

• anterior segment photos

• sometimes meibography, topography, etc.

It’s useful. It’s thorough. It’s also not always realistic—late arrivals, urgent add-ons, staffing gaps, equipment down, double-booked schedules.

And the trap is this:
“If I can’t do everything, I can’t do anything.”

Clinically, that’s not true.
Billing-wise, it can get you into trouble if you start “forcing” tests without clear necessity or documentation—especially when the visit was really a triage visit.

So here’s a doctor-facing way to think about it: build two legitimate visit types that are both medically sound and cleanly billable.

Two-visit model: “Triage Today, Baseline Later”

Visit A: The Minimum Safe Visit (Triage / Problem-Focused) Often During the Comprehensive Exam

This is the visit when the patient has multiple complaints, a routine complaint or is late, urgent, complex, or you simply don’t have the runway.

Clinical goal: rule out can’t-miss pathology, stabilize symptoms, start a plan.

Billing goal: bill the visit for the work you actually did (history/exam + MDM), and only bill tests that were actually necessary today.

What this looks like in documentation:

• A focused HPI that supports the problem and acuity (symptoms, triggers, prior treatments, contact lens history, vision changes, pain/photophobia, systemic meds, autoimmune history, surgery/laser history).

• Key exam elements that matter now (VA, lids/lashes, tear film, staining, conjunctiva, cornea, A/C if indicated).

• Clear assessment + plan (treatments started, warnings, and why follow-up testing is needed).

Coding options (conceptually):

• E/M (9920x / 9921x) if you’re billing E/M under 2021 rules (MDM or time).

• Eye codes (9200x / 9201x) if that’s your established pattern and documentation fits your payer rules.

(The “right” family depends on your specialty/payer contracts and what you actually document; don’t mix styles just to chase a number.)

Visit B: The Diagnostic Baseline Visit (Optimization / Measurement)

This is where you do the beautiful, comprehensive dry eye workup.

Clinical goal: quantify severity, identify drivers (evaporative vs aqueous deficiency, inflammatory component, anatomic contributors), establish baseline metrics.

Billing goal: tests are supported because they answer a question that changes management and you have time to do the documentation right.

The billing principle that keeps you safe

Don’t bill a test because it’s part of your “standard dry eye package.”
Bill a test because it was medically necessary for that patient that day, and you documented:

1. why you did it (the question it answers), and

2. how it affected assessment/plan (at least briefly).

That’s the clinic equivalent of not answering radio questions that don’t change the landing.

Common dry eye-related codes: when they fit and what to document

Below are the ones that tend to show up most in dry eye clinics. (Exact coverage varies by payer—so treat this as documentation logic, not a promise of payment.)

83861 — Tear osmolarity

Use when you’re evaluating tear film stability/aqueous deficiency severity and it informs treatment intensity, follow-up interval, or escalation (Rx drops, plugs, procedural pathway).

Document:

• symptoms + dry eye suspicion

• reason osmolarity was needed today

• result and what you did with it (therapy choice, escalation, follow-up)

83516 — Immunoassay (commonly used for MMP-9 / inflammatory marker)

Use when clinical picture suggests inflammatory dry eye and a result affects anti-inflammatory therapy decisions.

Document:

• inflammation suspicion (burning, fluctuating vision, staining, lid margin disease, etc.)

• result (pos/neg) and management change (steroid pulse, cyclosporine/lifitegrast, lid regimen, follow-up)

92285 — External ocular photography

This can be appropriate in dry eye when you’re documenting visible pathology that needs a picture for:

• severity tracking (lid margin disease, blepharitis findings, exposure, conjunctival changes)

• surgical/procedural planning

• documentation of a lesion or significant finding

The big compliance point: this code expects an interpretation and report (not just “photo taken”). In plain language: you need a brief statement of what the photo shows and why it matters.

Document:

• what was photographed and why

• findings seen on image

• how it supports diagnosis or plan

• comparison if relevant (baseline vs follow-up)

68761 — Punctal occlusion (plugs)

When you place plugs and it’s medically necessary.

Document:

• indication (aqueous deficiency, staining, failed conservative therapy, etc.)

• laterality, type/size if relevant, tolerance

• and if billing an E/M the same day, make sure your E/M is separately identifiable (often modifier -25, payer-dependent)

The “MGD blepharoconjunctivitis flare up masquerading as acute conjunctivitis” example: what clean looks like

Scenario: patient is 20 minutes late, you have 10 minutes.

Clean clinical + billing approach:

• Do focused history + slit lamp essentials + staining.

• Identify the working diagnosis (evaporative vs aqueous vs mixed, blepharitis/MGD, exposure).

• Start treatment (lubrication plan, lid hygiene, short steroid if appropriate, Rx anti-inflammatory plan, etc.).

• Schedule a baseline diagnostic visit for osmolarity/MMP-9/photos/meibography if needed.

What to avoid:

• “Let’s run the whole battery because that’s what we do for dry eye.”

• Billing multiple tests with no clear reason they were needed that day.

• Dropping photos into the chart without an interpretation/report and still billing 92285.

A simple documentation template you can copy/paste

Assessment: Dry eye syndrome OU, mixed mechanism suspected (MGD + aqueous component).
Why testing today: patient late/urgent; deferred advanced metrics to baseline visit.
Critical exam today: staining pattern, lid margin/MGD assessment, corneal integrity, vision impact.
Plan today: start X, Y, Z; warnings reviewed; follow-up in ___ for baseline testing to guide escalation.

If you did a test today, add one sentence:

• 83861: “Osmolarity performed to quantify tear film instability and guide escalation; result ___; starting ___; recheck ___.”

• 83516: “Inflammatory marker performed due to suspected inflammatory component; result ___; initiating/deferring ___.”

• 92285: “External photos obtained to document ___; photo shows ___; supports ___; will compare at follow-up.”

The real takeaway

The best dry eye clinics don’t just have great protocols—they have good sequencing.

When the day is messy, you can still take excellent care of the patient, and you can still code cleanly, if you separate:

• what you need to do today to make the next safe decision
  from

• what you want to measure later to optimize outcomes

This system protects attention, time, and medical necessity without cutting corners so both care and billing hold up when someone looks closely.