cpt code for phototherapy of newborn cpt code for phototherapy of newborn

ol.numberedList LI { Hyperbilirubinemia in the term newborn. The following are general age-in-hours specifictotal serum bilirubin (TSB)threshold values for phototherapy based upon gestational age and the presence or absence of risk factors (isoimmune hemolytic disease, glucose-6-phosphate dehydrogenase [G6PD] deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin of less than 3.0 g/dL [if measured]): Footnotes* Low Risk: 38 weeks gestation and without risk factors; Medium Risk: 38 weeks gestation with risk factors or 35 to 37 6/7 weeks gestation without risk factors; High Risk: 35 to 37 6/7 weeks gestation with risk factors. Tin-mesoporphyrin is not approved by the U.S. Food and Drug Administration. It is an option to provide conventional phototherapy in hospital or at home at TSB levels 2 - 3 mg/dL below those shown, but home phototherapy should not be used in any infant with risk factors. Several risk factors for hyperbilirubinemia are known, but in a large number of patients, a causal factor is never established. One infant (1.6%) met all three AAP guideline criteria of being DAT-positive, bilirubin within 3 of exchange level, and rising bilirubin despite intensive phototherapy. Oral zinc was administered in a dose of 5 ml twice-daily from day 2 to day 7 post-partum. TcB consistently under-estimated TSB levels significantly. The pediatrician notes the abnormal results have implications for future healthcare. 2008;93(2):F135-F139. It is also important to note that thereare serious health risks associatedwith corticosteroid therapy. This review included total of 10 RCTs (2 in preterm neonates and 8in term neonates) that fulfilled inclusion criteria. 92586 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system, limited Approximately 10 to 20 percent of newborns have an umbilical hernia. Valaes T. Problems with prediction of neonatal hyperbilirubinemia. cpt code for phototherapy of newborn list-style-type: lower-roman; BiliCheck variability (+/- 2 SD of the mean bias from serum bilirubin) was within -87.2 to 63.3 micromol/L, while BiliMed variability was within -97.5 to 121.4 micromol/L. Lets review which conditions should be reported and when. 'New' bilirubin recommendations questioned. Two reviewers screened papers and extracted data from selected papers. cpt code for phototherapy of newborn - mycyberplug.com If the fractured clavicle does not use additional resources during the hospitalization (a safety pin is not additional resources), do not code the condition on the hospital encounter. CETS 99-6 RE. So why would you not use one of the codes from 99221-99223 for the first day? Mothers typically are counseled on newborn jaundice signs and when to bring the newborn in. The beroptic system consists of a pad of Home phototherapy. .fixedHeaderWrap { Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. These investigators also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for RCTs and quasi-randomized trials. If no feeding or other health problem has been previously noted, this visit may be the first well-child visit when provided by a physician, nurse practitioner, or physician assistant. Code 99477 represents initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services. Newborn admit for jaundice coding | Medical Billing and Coding Forum - AAPC TcB measurements obtained on the forehead, sternum, abdomen and covered lower abdomen were statistically compared with the corresponding TSB. The increased bilirubin from hemolysis often needs phototherapy, exchange transfusion or both after birth. The authors concluded that the UGT1A1*28 allele was not associated with risk for extreme hyperbilirubinemia in this study. With the common genotype as reference, the odds ratio of extreme hyperbilirubinemia was 0.87 (range of 0.68 to 1.13) for UGT1A1*28 heterozygotes and 0.77 (range of 0.46 to 1.27) for homozygotes. Can Nurse. 2015;7:CD008432. UGT1A1 is the rate-limiting enzyme in bilirubin's metabolism. } Acta Paediatr. The G6PD 1388 G>A, SLCO1B1 rs4149056 and BLVRA rs699512 SNPs had a significant impact on STB levels. I have a provider that ordered phototherapy for a newborn in the hospital with jaundice and he is wanting to bill 96900. Second, according to Cochrane risk of bias estimation, randomized allocation of participants was mentioned in 9 trials. CPT offers 3 coding options for initial encounter with ill newborn A condition does not need to be coded on the inpatient hospital encounter to be coded on the pediatricians hospital encounter. PLoS One. Home Phototherapy } Now, newborns are checked with a transcutaneous bilirubinometer, and the pediatrician reviews standard laboratory blood screenings. Testicles develop in the abdomen. For most newborns, hematomas from the birth process resolve spontaneously. Most newborns have ointment administered at birth, or soon after the initial bonding with the mother. Yang L, Wu, Wang B, et al. Procedures included in the services represented by code 99477 include those listed for the Critical Care Services subsection of CPT (codes 99291 and 99292), as well as additional procedures listed in the Inpatient Neonatal and Pediatric Critical Care subsection (codes 99468-99476, 99466-99467). Phototherapy was well-tolerated without evidence of significant photo-damage or photo-carcinogenicity. } Arch Dis Child Fetal Neonatal Ed. J Matern Fetal Neonatal Med. color: blue!important; 99460-99461 initial service 2. PDF CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia - Health Net Oregon 1993;32:264-267. The USPSTF and the Agency for Healthcare Research and Quality (2009) reported on the effectiveness of various screening strategies for preventing the development of CBE. If the newborn jaundice is excessive, hospitals use bili lights. Additionally, no serious adverse reaction was reported. Toggle navigation. A total of 259 neonates were included in the meta-analysis. Treatment effects on the following outcomes were determined: mean change in bilirubin levels, mean duration of treatment with phototherapy, number of exchange transfusions needed, adverse effects of clofibrate, bilirubin encephalopathy and neonatal mortality. 66850 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration. With time, the lacrimal ducts mature and the membrane covering the nasolacrimal ducts open. The authors concluded that effects of screening on the rates of bilirubin encephalopathy are unknown. Ambalavanan N, Carlo WA. The primary outcome was a composite of death or neurodevelopmental impairment determined for 91 % of the infants by investigators who were unaware of the treatment assignments. Cases were identified in the Danish Extreme Hyperbilirubinemia Database that covers the entire population. Subgroup analysis was done for AB0 incompatible cases. color: red 1992;89:809-818. .newText { Inpatient treatment is generally not medically necessary for healthy full-term infants with aTSB less than 20 mg/dL, as these infants can usually be treated with expectant observation or home phototherapy. They considered all RCTs that studied neonates comparing enteral feeding supplementation with prebiotics versus distilled water/placebo or no supplementation. The pooled estimates of correlation coefficients (r) during phototherapy were: covered sites 0.71 (95 % CI: 0.64 to 0.77, 11 studies), uncovered sites 0.65 (95 % CI: 0.55 to 0.74), 8 studies), forehead 0.70 (95 % CI: 0.64 to 0.75, 12 studies) and sternum 0.64 (95 % CI: 0.43 to 0.77, 5 studies). The efficacy of intravenous fluid supplementation for neonatal hyperbilirubinemia: A meta-analysis of randomized controlled studies. Our providers amend their office note to indicate the patient was admitted due to results then charge an Initial Outpatient Care code (99218-99220) for the day of admission and then 99217 for discharge. The total number of neonates enrolled in these different RCT were 749. Metalloporphyrins for treatment of unconjugated hyperbilirubinemia in neonates. Prediction of hyperbilirubinemia in near-term and term infants. These services include intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the health care team under direct physician supervision. When the pediatrician spends additional time explaining the skin condition, and the findings affect the episode of care, it should be coded on professional encounters. Pediatrics. When no additional resources are used, this is not coded on the inpatient record, and is part of the pediatricians well-baby check. Search All ICD-10 Toggle Dropdown. Take your newborn's temperature every 3 to 4 hours. Kernicterus. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks gestation). Notes: Prophylactic phototherapy is considered medically necessary for infants showing a rapid rise in bilirubin (greater than 1 mg/dL/hour) and as a temporary measure when one is contemplating exchange transfusion. Petersen JP, Henriksen TB, Hollegaard MV, et al. J Adv Nurs. As with the initial critical care, only one physician may report code 99469 on a given date. When the hematoma is extensive or combined with other issues that cause excessive hemolysis, involving additional resources, look to P58 Neonatal jaundice due to other excessive hemolysis. 2006;117(2):474-485. Last Review04/29/2022. All but 1 of the included studies were conducted in Iran. The authors concluded that early DXM treatment does not affect the severity of neonatal hyperbilirubinemia in ELBW preterm infants. Neonatal Hyperbilirubinemia - Medical Clinical Policy Bulletins | Aetna Hospital readmission due to neonatal hyperbilirubinemia. The following are general age-in-hours specificTSBthreshold values forexchange transfusionbased upon gestational age and the presence or absence of risk factors (isoimmune hemolytic disease, glucose-6-phosphate dehydrogenase [G6PD] deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin ofless than 3.0 g/dL [if measured]): Footnotes* Low Risk: 38 weeks gestation and without risk factors; Medium Risk: 38 weeks gestation with risk factors or 35 to 37 6/7 weeks gestation without risk factors; High Risk: 35 to 37 6/7 weeks gestation with risk factors. OL OL LI { 65. cpt code for phototherapy of newborn - smujsuperfoods.com All the studies used zinc sulfate, only 1 study used zinc gluconate. 1986;25(6):291-294. color: #FFF; Gu J, Zhu Y, Zhao J. As a family physician, you may also address needs of the mother during a newborn's encounter (e.g., lactation problems). OL OL OL LI { Curr Opin Pediatr. San Carlos, CA: Natus Medical Inc.; 2002. color: blue Once the skin is clear or alm Chen and co-workers (2017) stated that probiotics supplementation therapy could assist to improve the recovery of neonatal jaundice, through enhancing immunity mainly by regulating bacterial colonies. Phototherapy in the home setting. Elk Grove Village, IL: AAP; 1997. 2023 ICD-10-PCS Codes 6A6*: Phototherapy - ICD10Data Per the ICD-10-PCS Official Guidelines for Coding and Reporting, only clinically significant conditions are reported. Codes 99478-99480 each are described as, "Subsequent intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant" with the code selected based. Makay B, Duman N, Ozer E, et al. Usually, procedures coded: Low-cost, low-risk screening and prevention procedures usually are not coded. 6A650ZZ - Phototherapy, Circulatory, Single Version 2023 Billable Code ICD-10-PCS Details 6A650ZZ is a billable procedure code used to specify the performance of phototherapy, circulatory, single. Indian Pediatr. In general, serum bilirubin levels . Use a cupped hand or percussor cup. If the condition involves a diagnostic study, however, it is coded. Date of Last Revision: 10/22 . This is usually associated with one of the codes from Q65 Congenital deformities of the hip. Although an undescended testicle usually is described as palpable or impalpable, also get the location, if you can. Grabert BE, Wardwell C, Harburg SK. This generally refers to an undescended or maldescended testis. Aetna considers massage therapy experimental and investigational for the treatment ofneonatal hyperbilirubinemia because its effectiveness has not been established. 1994;61(5):424-428. However, only 1 trial (out of 2) reported significant reduction in bilirubin levels in preterm neonates. An example is hemangiomas (e.g., strawberry hemangiomas), which do not impinge on vital structures and are not located in the periorbital area, lip, neck, or sacral region. Furthermore, an UpToDate review on "Evaluation of unconjugated hyperbilirubinemia in term and late preterm infants" (Wong and Bhutani, 2017) states that "TcB measurements are not reliable in infants undergoing phototherapy. A total of 14 studies were identified. Transcutaneous bilirubinometry in the context of early postnatal discharge. Everything I am finding indicates this code is used for dermatological treatment not for jaundice. Casnocha Lucanova L, Matasova K, Zibolen M, Krcho P. Accuracy of transcutaneous bilirubin measurement in newborns after phototherapy. Evans D. Neonatal jaundice. } The initial day of critical care for the evaluation and management of a critically ill neonate, 28-days of age or less, is reported with code 99468. Language services can be provided by calling the number on your member ID card. For preterm neonates, there was a significantly lower bilirubin level in the 100 mg/kg clofibrate group compared to the control group with a mean difference of -1.37 mg/dL (95 % CI: -2.19 mg/dL to -0.55 mg/dL) (-23 mol/L; 95 % CI: -36 mol/L to -9 mol/L) after 48 hours. An UpToDate review on "Evaluation of unconjugated hyperbilirubinemia in term and late preterm infants" (Wong and Bhutani, 2015) does not mention genotyping of SLCO1B1 and UGT1A1 as management tools. Home phototherapy with the fiberoptic blanket. The order of use of the instruments was randomized. top: 0px; Clinical Policy: Phototherapy for Neonatal Hyperbilirubinemia Reference Number: CP.MP.150 Coding Implications . newborn, known as hyperbilirubenemia. Reference No. Malpresentations are almost always noted on the inpatient record. at the end of this policy for important regulatory and legal information. Because this is a normal condition, there is no code for it. 66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852) Learn more about pediatric cataract billing in Ophthalmic Coding: Learn to Code . Coding for Newborn Care Services (99460, 99461, & 99463) | AAFP Typically, no extra resources are required during the newborn hospitalization, so do not code the condition. These usually heal and resolve on their own. } Watchful Waiting: Collecting Newborn Information Two hundred years ago, newborns would have been placed on blankets in the sun for newborn jaundice. Do I Use 25 or 59 for Same-day Assessment and E/M? Aetna considers zinc supplementation for the prevention of hyperbilirubinaemia experimental and investigational because its effectiveness has not been established. Support teaching, research, and patient care. J Perinatol. Even if it meets the technical meaning of conjunctivitis (inflammation of the conjunctiva), it isnt contagious; its self-limiting and does not affect medical decision-making, so it cannot be coded on the pediatricians encounter. In a Cochrane review, these investigators examined if administration of prebiotics reduces the incidence of hyperbilirubinemia among term and pre-term infants compared with enteral supplementation of milk with distilled water/placebo or no supplementation. Ch. J Matern Fetal Neonatal Med. According to available guidelines, inpatient treatment may be considered medically necessary for healthy full-term infants who present with aTSB greater than or equal to 20 mg/dL in the first post-natal week. The authors stated that this study had several drawbacks. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically becomes visible on day 3, peaks days 5-7 and resolves by 14 days of age in a term infant and by 21 days in the preterm infant. Only one physician may report this code. } Jaundice, Coombs, and Phototherapy AAP Clinical Practice Guideline - Summary Bhutani Nomogram Guidelines for Phototherapy FAQs About Phototherapy Cochrane Database Syst Rev. The therapy may be in the form of a lamp, light panel, or special light blanket. Deshmukh and associates (2017) noted that neonatal jaundice requiring phototherapy is associated with significant socioeconomic burden including hospital re-admission, prolonged hospital stay, and separation of the baby from mother. J Pediatr Gastroenterol Nutr. Travan L, Lega S, Crovella S, et al. None of the included studies reported any side effects. Garg and colleagues (2017) stated that neonatal hyperbilirubinemia (NNH) is one of the leading causes of admissions in nursery throughout the world. 1992;31(6):345-352. For most newborns, the transition from fetal to newborn blood simply involves watchful waiting. Gholitabar M, McGuire H, Rennie J, et al. Management of neonatal hyperbilirubinemia. All studies were found to be of low-risk based on Cochrane Collaborative Risk of Bias Tool. The RR or MD with a 95 % CI was used to measure the effect. The SLCO1B1 521 T>C mutation showed a low risk of neonatal hyperbilirubinemia in Chinese neonates, while no significant associations were found in Brazilian, white, Asian, Thai, and Malaysian neonates. Bhutani VK, Stark AR, Lazzeroni LC, et al; Initial Clinical Testing Evaluation and Risk Assessment for Universal Screening for Hyperbilirubinemia Study Group. 99462 3. Porter ML, Dennis BL. Discharge normal newborn day 3 _____ 2. Pediatrics. If the nurse visit results in a visit with the physician, only the physician services would be reported. For more information about blocked lacrimal ducts, visit: aao.org/eye-health/diseases/treatment-blocked-tear-duct. If a nurse visit is provided (e.g., weight screen only), code 99211 may be reported. Nagar G, Vandermeer B, Campbell S, Kumar M. Effect of phototherapy on the reliability of transcutaneous bilirubin devices in term and near-term infants: A systematic review and meta-analysis. French S. Phototherapy in the home for jaundiced neonates. Codes for initial care of the normal newborn include: After the newborn has been discharged to home, it is common practice to see the infant to assess for jaundice or any feeding problems. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2002. Maisels MJ, Watchko JF. Pediatrics. Nelson Textbook of Pediatrics. However, there was insufficient evidence to recommend their use because of inadequate data on safety and long-term outcomes. Pediatrics. Phototherapy for neonatal jaundice. 2017:1-9. Furthermore, an UpToDate review on "Treatment of unconjugated hyperbilirubinemia in term and late preterm infants" (Wong and Bhutani, 2016) does not mention zinc supplementation as a management tool. . Percussion should not cause red marks on your child. Do not use S42.0- Fracture of clavicle for the initial encounter or subsequent professional encounters. 1998;101(6):995-998. RM Kliegman, BF Stanton, JW St. Geme, et al., eds. Moreover, these investigators stated that infants with bilirubin levels greater than 25 mg/dL, those who are not responding to phototherapy, and those with evidence of acute bilirubin encephalopathy should be treated with exchange transfusion, with initiation based on an infants age in hours and neurotoxicity risk factors. Approximately one in 1,000 children have congenital developmental dysplasia of the hip, which is coded Q65.89 Other specified congenital deformities of hip. The receiver operating characteristic analysis (for serum bilirubin levels greater than 205.2 micromol/L or greater than 239.4 micromol/L) showed significantly higher areas under the curve for BiliCheck than those for BiliMed (p < 0.001). J Matern Fetal Neonatal Med. In preterm infants, phototherapy should be initiated at 50 to 70 % of the maximum indirect levels below: Footnotes* Complications include but are not limited to prenatal asphyxia, acidosis, hypoxia, hypoalbuminemia, meningitis, intraventricular hemorrhage, hemolysis, hypoglycemia, or signs of kernicterus. Pediatrics. Compared with hospital-based phototherapy, home-based phototherapy appeared more effective for the treatment of neonatal hyperbilirubinemia in reducing the rate of total serum bilirubin (standard mean difference [SMD] = 0.32, 95 % CI: -0.22 to 0.86, p = 0.04); however, there was no signicant difference in duration of phototherapy (SMD = 0.59, 95 % CI: 0.28 to 0.90, p = 0.06) in the 2 groups. Guidelines from the Canadian Paediatric Society (2007) found that phenobarbitol, studied as a means of preventing severe hyperbilirubinemia in infants with G6PD deficiency, did not improve clinically important outcomes in a randomized controlled clinical study (Murki et al, 2005). Secondary outcomes included incidence of jaundice, TSB level at 24, 48, 72, 96hours, and day 7, duration of hospital stay, and adverse effects (e.g., probiotic sepsis). 2010;15(3):164-168. Although inflammation occurs less frequently now than in the past because the medication used has changed, it may occur. A recent retrospective case-controlled study showed reduction in the need for exchange transfusion for the neonates from isoimmunized pregnancies. (Codes may be selected based on time spent in counseling and coordination of care when documentation indicates more than 50% of face-to-face time was spent in these activities.) A randomized, triple-blind, placebo-controlled trial of prophylactic oral phenobarbital to reduce the need for phototherapy in G6PD-deficient neonates. Eye issues due to immaturity or from the ointment applied to the newborns eyes. J Perinatol. The results revealed that SLCO1B1 388 G>A is associated with an increased risk of neonatal hyperbilirubinemia (odds ratio [OR], 1.39; 95 % CI: 1.07 to 1.82) in Chinese neonates, but not in white, Thai, Latin American, or Malaysian neonates. } Only 1 study met the criteria of inclusion in the review. 2007;44(3):354-358. Phototherapy Coding and Documentation in the Time of Biologics 1994;94(4 Pt 1):558-565 (reviewed 2000). These include vascular access procedures, airway and ventilation management services, oral or nasogastric tube placement, bladder aspiration or catheterization, and lumbar puncture among others. Accessed July 16, 2002. The code is valid for the year 2023 for the submission of HIPAA-covered transactions. on Watchful Waiting:Collecting Newborn Information, Watchful Waiting:Collecting Newborn Information, Tech & Innovation in Healthcare eNewsletter, Capture Active Duty Diagnoses with DoD Unique Codes, Finally Tobacco Use That Isn't a Mental Health Issue, Know Your Payer to Make the Most of Modifier 24, Modifier 25 for E/M on the Day of an Injection Procedure. Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. cpt code for phototherapy of newborn - malaikamediatv.com phototherapy in the home, applied by a . Morris and colleagues (2008) compared aggressive versus conservative phototherapy for infants with extremely low birth weight. This is not the same as for professional services coding, where the first-listed diagnosis is the reason for the encounter. Rates of death in the aggressive-phototherapy and conservative-phototherapy groups were 24 % and 23 %, respectively (relative risk, 1.05; 95 % CI: 0.90 to 1.22). 2002;3(1). 1998;94(1):39-40. Aggressive phototherapy did reduce rates of neurodevelopmental impairment (26 %, versus 30 %for conservative phototherapy; relative risk, 0.86; 95 % CI: 0.74 to 0.99). Total serum bilirubin concentrations peaked 30 hours earlier in the DXM group (p 0.05). Hospitals typically decide the data provided by 3E0CX2 is not coded because it takes time to collect, clutters the rest of the data, and does not provide information to improve patient care or efficiency. Normal newborn care services are reported with these codes: 99460 Initial hospital or birthing center care, per day, for E/M of normal newborn infant 99462 Subsequent hospital care, per day, for E/M of normal newborn The Coding for Pediatrics manual defines a normal newborn as the following: Transitions to life in the usual manner. Although early corticosteroid treatment facilitates extubation and reduces the risk of chronic lung disease and patent ductus arteriosus, it causes short-term adverse effects including gastro-intestinal bleeding, intestinal perforation, hyperglycaemia, hypertension, hypertrophic cardiomyopathy and growth failure. .strikeThrough { Centers for Disease Control and Prevention (CDC). Chen Z, Zhang L, Zeng L, et al. Schuman AJ, Karush G. Fiberoptic vs conventional home phototherapy for neonatal hyperbilirubinemia. These investigatorscalculated the sensitivity and specificity of early TSB, TcB measurements, or risk scores in detecting hyperbilirubinemia. Description This policy details medical necessity criteria for home phototherapy for the treatment of neonatal . Since then, many hundred thousand infants have been treated with light. Kernicterus in full-term infants--United States, 1994-1998. If time is not significant, and it does not impact medical decision-making, it does not meet the definition of an additional professional encounter diagnosis. Halliday HL, Ehrenkranz RA, Doyle LW. It is an option to provide conventional phototherapy in hospital or at home at TSB levels 2 - 3 mg/dL below those shown, but home phototherapy should not be used in any infant with risk factors. cpt code for phototherapy of newborn - colspiritlifecoaching.com FAQs About Phototherapy | Newborn Nursery | Stanford Medicine The authors concluded that current studies are unable to provide reliable evidence regarding the effectiveness of prebiotics on hyperbilirubinemia. PubMed, Embase, Web of science, EBSCO, Cochrane library databases, Ovid, BMJ database, and CINAHL were systematically searched; RCTs evaluating the effect of zinc sulfate versus placebo on the prevention of jaundice in neonates were included. Data were statistically extracted and evaluated using RevMan 5.3 software. Sacral dimples without diagnostic services, such as diagnostic imaging, are not coded on inpatient records. For inpatient hospital coding, a condition is clinically significant if it requires: Note: These perinatal guidelines are the same as the general coding guidelines for additional diagnoses, except for the final point regarding implications for future healthcare needs. Until the lacrimal ducts drain spontaneously, the pediatrician can show the parents a massage technique to use between the bridge of the nose and the inside corner of the affected eye.