By Christopher Wolfe, OD, FAAO, Dipl. ABO

The comprehensive exam is doing a lot of heavy lifting these days. You’re checking refraction, ruling out sight-threatening disease, navigating billing codes, and trying to have a meaningful conversation about dry eye in under 30 minutes. It’s no wonder we feel like we’re trying to land a 747 on a backyard trampoline.

So how do we strike a balance between evaluating the whole visual system and giving ocular surface disease (OSD) the attention it deserves?

I’ll walk you through how I separate the two, not just philosophically, but clinically and from a billing perspective, so that we get better outcomes and get paid for the work we do. 

The Comprehensive Exam: The Non-Negotiables

I believe every comprehensive exam should include a dry eye screening. I mean a quick, high-yield assessment that actually means something to the clinician doing the exam.

Here’s what I ask every patient during their CE:

1. Are your eyes ever red?

2. Do your eyes get dry, burny, or gritty?

3. Do you ever use artificial tears?

4. Does your vision fluctuate?

That’s it. It takes less than 30 seconds, and it gives me a signal. But it’s not just the symptoms I’m looking for. I pair those simple questions with one clinical test I never skip: meibomian gland evaluation using a meibomian gland evaluator.

Why?

Because I believe if a patient has symptoms or has poor gland secretion, and I don’t act on that, there’s a good chance they’ll be worse off in a month, a year, or 10 years.  

Failure to act is on me. This is existential. I can’t unsee it. I can’t ignore it. And I don’t.

That’s why I start treatment immediately at the CE when either of those indicators are positive, usually with warm compresses and lid hygiene. 

And that lid hygiene? Peeq Pro is my go-to. It’s fast, effective against both bacteria and Demodex (thanks to the tea tree oil), and it simplifies the conversation with the patient, “Let’s wipe the slate clean and follow up in a month.”

When to Go Deeper: Triggering an OSDE

If the screening questions are positive or the meibomian gland secretions are poor, I don’t just send patients home with a hot pack, Peeq Pro, and good vibes.

I schedule them back in one month for a dedicated Ocular Surface Disease Evaluation (OSDE). Why? Patients deserve more than passive management for a chronic, progressive disease. If I’ve detected something worth treating, then it’s worth measuring, tracking, and managing over time, not just guessing at improvement.

In addition, I make sure to get the patient scanned into the Peeq Pro workflow. Patients should do what you recommend. They don’t. Peeq Pro ensures that they do through our proprietary workflow. Totally transformative.

The OSDE: What I Measure, and Why

At the OSDE visit, I perform the following essential tests:

• Meibography

• Staining with both fluorescein and lissamine green

• Tear meniscus height, which gives me similar value to a Schirmer test without the irritation and time

• Osmolarity testing (both eyes)

• Inflammatory marker (MMP-9) testing

• Evaluation of lid closure (looking for nocturnal lagophthalmos)

• Lid wiper epitheliopathy, especially if staining patterns suggest inflammation

These give me a comprehensive view of tear production, inflammation, evaporative potential, and mechanical contribution - all within a tight diagnostic window. And yes, if all these look clean but something still feels off, I’ll go further. 

But in most cases, this gets me to a strong diagnosis with a clear treatment path.

Billing and Coding the OSDE: Doing Good and Getting Paid

When I perform an OSDE, I typically bill a 99XXX-level E/M code, usually a 99213 or 99214, depending on problem type and risk of treatment. 

Importantly, I also bill the G2211 add-on code when appropriate. This code recognizes the work involved in longitudinal care and complex condition management — exactly what’s happening during an OSDE where I’m the primary provider managing their OSD.

Here’s the typical billing stack for an OSDE:

• 99213 or 99214 (based on problem type and risk)

• + G2211 (if the visit is part of ongoing OSD care)

• 92285 (anterior segment photography)

• 83861 (osmolarity test)

• 83516 (MMP-9 / InflammaDry test)

The key here is medical necessity and documentation. If you’re interpreting these tests and using them to guide management, AND YOU SHOULD BE, then they’re not “extra,” they’re essential.

Final Thoughts: What’s Your Line in the Sand?

If I could leave you with one takeaway, it’s this:
Find a few clinical indicators that you believe in so deeply, you refuse to ignore them.

For me, that’s dry eye symptoms and meibomian gland function during the comprehensive exam. I’ve drawn a line. If either one is off, I act. Every single time.

That’s how patients win. That’s how you build a thriving practice. And that’s how you make billing and coding work for you.

Let me say it plainly: If you’re not acting on something you believe is important, it’s just a bad habit dressed in clinical inertia.