billing and coding for maximum reimbursementtexas.aoa.org/documents/tx/2016 pcs/handout - morning...

7/16/2016

1

Billing & Coding for Maximum ReimbursementIn the new healthcare paradigm

Peter J. Cass, OD

Practice Compliance Solutions

Peter J. Cass, OD - Disclosures• Owner, Beaumont Family Eye Care Beaumont Texas• Vice President, Optometric Business Solutions • Sec/Tres TOA, Chair HIT Committee• AOA Health Information Exchange Workgroup• Consultant for ophthalmic companies: Alcon, Bausch +

Lomb, Crystal PM, Diopsys, Solution Reach, Katena, Lipflow• Shareholder Essentia• Lecturer for Professional groups: Vision Source, Vision West,

ECPN, PERC, Vision Trends, Vision West, TSO, others Consulting companies: ClienmanUniversities: RSO, UHCO, UAB, othersState associations: TOA, and over 20 others

Opportunities in Wellness Care• Population growth• 31% of children 6-16y/o haven’t had an eye exam in the last

24 months (Pediatrics)• Prevalence of vision disorders up 150% over the past 10

years• HUGE rural OD manpower shortage

Opportunities in Service• Online threats are REAL, but still only a percentage of

patients will buy on-line• The larger percentage of patients will always favor a private

practice doctor• The larger percentage of patients will always know that $29

or $40 eye examinations are not what they want for themselves or their family

Opportunities in MEDICAL Care• 70 million Boomers by 2030• Obesity sits at 33% - expected to hit 50% by 2020• 2011 – 9% of US population diabetic• 1:3 children born after 2000 expected to become diabetic• 21% increase in glaucoma• 70% increase in legal blindness by 2020• Prevalence of AMD through the roof

How can we tap into that?• Offer comprehensive care – wellness and medical• Offer individualized care – not generic care•Manage, not inappropriately refer your medical care• Be creative and aggressive in ophthalmic product options• Offer exceptional customer service • Be more efficient.

7/16/2016

2

Did John make you sad about the future of Vision Care?

Let’s fix it! Efficiency can make a difference

Keys to Efficiency• Scheduling• Training• Technology• Delegation

Average Practice• Patients Per hour 1.2

• Gross Per Patient $306.00

• Gross Per Day $2,500.00

Scheduling

AM14

Comp

PM16

Comp

AM8

Short

PM8

Short

Production

7/16/2016

3

Scheduling• Start out small• Change your schedule templates• Add 1 in the AM &

Add 1 in the PM• Utilize your staff

How long does an exam take

• 15 min check in (no forms so usually less)• 15 min work up

(usually less than 10)• 15 min exam

(usually less than 10)• 15 min optical

How long should an exam take• Prima Eye Group has looked into this, applying Disney

Institute studies to eye care• If the visit takes too long, patients get anxious • Varies from person to person •Willingness to spend declines with time• Office visits should probably be between 15 and 60 mins • Start getting anxious at 45 min mark

Routing Slips

• Control flow•Write Quick notes

Patient Satisfaction

• 96% Excellent or very good

Staff

• You may need more staff• I have 9 (2 assistants)1 COA who works up1 COA to assist

•21% staffing

7/16/2016

4

Staff

•Hire Personality

•Hire Intelligence

• Train everything else

Training makes all the difference

Staff Training Staff Training

What do you have to do?

Texas Optometry Act Sec. 351.353. INITIAL EXAMINATION OF PATIENT.

To ensure adequate examination of a patient for whom an optometrist or therapeutic optometrist signs or causes to be signed an ophthalmic lens prescription, in the initial examination of the patient the optometrist or therapeutic optometrist shall make and record, if possible, the following findings concerning the patient's condition: (1) case history, consisting of ocular, physical, occupational, and other pertinent information; (2) visual acuity; (3) the results of a biomicroscopy examination, including an examination of lids, cornea, and sclera; (4) the results of an internal ophthalmoscopic examination, including an examination of media and fundus; (5) the results of a static retinoscopy, O.D., O.S., or autorefractor; (6) subjective findings, far point and near point; (7) assessment of binocular function; (8) amplitude or range of accommodation; (9) tonometry; and (10)angle of vision, to right and to left.

Minimum Competency

Minimum1) History2) Visual Acuity3) Biomicroscopy4) Internal ophthalmosmoscopy5) Retinoscopy6) Subjective refraction7) Binocular vision8) Amplitude of accommodation9) Tonometry10) Angle of vision

7/16/2016

5

Procedures done by StaffTypical Office

1) History

2) Visual Acuity

3) Auto Retinoscopy

4) Tonometry

My office

1) History, HPI, CC, Ocular, 2) Med history3) Social, Family4) Meds, Allergies5) ROS6) Lensometry7) AR / AK8) Optomap9) Visual Acuity

Procedures done by StaffTypical Office My office

• Tonometry • Binocular vision• Pupils• Cover Test• Visual Fields• Color• Stereo • Mental Status• Height / Weight• Blood Pressure• Dilation

Procedures done by StaffTypical Office My office

• Topography• External Photography• Fundus Photography• VF• OCT• Pachymetry• Specular Microscope• VEP / ERG• CL assessment• CL follow up

Minimum Competency (Exam for an established patient)

• Not specified“To ensure adequate examination of a patient for whom an optometrist or therapeutic optometrist signs or causes to be signed an ophthalmic lens prescription, in the initial examination of the patient the optometrist or therapeutic optometrist shall make and record, if possible, the following findings concerning the patient's condition:”

Lets talk Technology

Technology

• Need Equipment

7/16/2016

6

Utilize technology in Pretesting• Auto Refraction / Auto Keratometry

Utilize technology in Pretesting• iCare tonometry

Utilize technology in Pretesting• Optos

Technology• Need EHR• Customize

Technology• Integration

EHRs• Scribing• Auto prompting• Auto fill

7/16/2016

7

Patient Education• Staff can help• Letters

Delegation

Pre - Dilation• Phenylephrine

Cyclopentolate• Train staff when to use

Have staff prepare exam room• Set Refractor

• Open Chart

• Review Chart

Dilation• Have staff do it• Leave them in the room

7/16/2016

8

Samples• Staff can pass these out

Handoff - CLs

Handoff - Spectacles Special Testing• External Photos• Internal Photos• Topography• GDx• VF• OCT• IOP• Pachymetry• Specular Microscopy

Soft CLs Fits• Pull lenses• Trouble shoot soft fits• Order trials

RGP CLs Fits• Pull and prep RGP lenses• Clean and store RGP lenses• Document• Order

7/16/2016

9

CL Follow ups

• Staff can do it•Who cleans your teeth?

Letters• Staff can write

• Staff can print

• Just review & sign

Referrals• Staff can make and return phone calls for you

Patient Forms

Pharmacy Calls Other efficiencies

7/16/2016

10

Economics• Adding 2 Per day$300 per patient$12,000 Gross per month

• $3,600 NET per month!

• Or free up ½ day

Did John make you sad about the future of Medical Care?

Let’s fix it! Practice like a doctor

Optometry’s Opportunities• Are you prescribing like a doctor?AntibioticsAntihistamine / Mast cell stabilizersSteroidsProstaglandin AnalogsImmunosuppressants

So, Who Is Taking Care of Eyes?• 82% of physicians writing prescriptions for ophthalmic drugs

were NON-EYE CARE PRACTITIONERS!!!!!• Non-eye doctors write more glaucoma scripts than

optometrists• Non-ophthalmic MDs write more ocular allergy medications

than optometrists• Optometrists see 70% of the patients and in general

prescribe only 10-20% of all meds

E-Prescribing• E-Prescribing makes it easy• Pick the med, E-prescribing system shows complete name, dosage strength, strength units, dosage form, and route of administration information

7/16/2016

11

“Sampling” Meds Hurts Your Practice

• Significantly reduces patient compliance•Minimizes the doctor image associated with the “power of

the pad”• Fails to support the corporate sponsors who help us• Script your patients, sample your family

Ocular allergy diagnosis• Self-diagnosed / self-medicated with only marginal success• Studies say prevalence of 15-25% (some say 40%)• Signs & Symptoms:Conjunctival injection (mild to moderate)Chemosis (moderate)ItchingTearingwhite mucus“Glassy appearance”

Ocular allergy treatment• Be the doctor who makes a difference for the patient• Lots of optionsBepreveLastacaftPazeoAlrex / LotemaxPrednisoloneDurezolTopical cyclosporine

•Write a script! Don’t sample!

Ocular allergy follow up•Minimal follow up needed• Improvement much better than with OTC drops• Patients will remember who treated them• Patients will refer others• Patients more likely to return for other care

Glaucoma medications• Don’t be afraid to prescribe• 82% of prescribers are NON-EYE CARE PRACTITIONERS!• Lots of optionsAlpha AgonistsBeta blockersCAIsMioticsCombinations

• Prostaglandin analogs safe, effective, well tolerated

Dry Eye Medications & Follow up• Patients are symptomatic and looking for someone to help• Huge potential for your practice•Medication optionsTopical Cyclosporine Steroids

• Give them an OTC recommendation and you might as well give them a referral to your colleague down the road• Actual treatment requires follow up (and you can bill for it!)• Patients will appreciate it and refer others

7/16/2016

12

FIRST QUESTION:• How Comfortable Are You Diagnosing Retinal And Optic

Nerve Disorders? I’m better than Mark Dunbar, Diane Schektman, and Bill

Jones all combinedI’ve actually seen diabetic macular edema and may know

it if I see it againI haven’t had a call from an attorney….yetI’m pretty good with a Welch-Allyn direct - when the

bulb is workingI’m pretty sure my OptoMap has me covered!

SECOND QUESTION• How many of these do you see each month? (or miss!) GlaucomaARMDCystoid Macular EdemaDiabetic RetinopathyCentral Serous RetinopathyIdiopathic Epiretinal MembraneMacular CystOptic Nerve DrusenAnterior Ischemic Optic NeuropathyPigment Epithelial DetachmentPeripheral retinal holeLamellar macular hole

THIRD QUESTION:• If you did see them, which ones need a referral to ophthalmology?GlaucomaARMDCystoid Macular EdemaDiabetic RetinopathyCentral Serous RetinopathyIdiopathic Epiretinal MembraneMacular CystOptic Nerve DrusenAnterior Ischemic Optic NeuropathyPigment Epithelial DetachmentPeripheral retinal holeLamellar macular hole

FOURTH QUESTION

•Since The Answer Is Almost None - WHO Are You Making Rich?Retina Specialist - badGlaucoma Specialist - worseGeneral Ophthalmologist – the worstAll the above - unspeakable

•Or…YOU!!!!

How to increase medical care?• Quack Like A Duck

• Say you take care of the medical aspects of eye care everywhere – office, website, brochures, business cards

•Most importantly, tell your PATIENTS and medical colleagues what you do

Get Copies of Medical Insurance Card

• Tells your patient you do medical!• Allows your patient to better utilize their health care

benefits• At a minimum, lets you know what you’re missing out on• Lets you know what plans you want to be on

7/16/2016

13

How Do I Build A Medical Practice?

• Grow Like A Duck

• Invest in knowledge and technology

• You ultimately learn by doing

• Associate with other ducks –optometrists are your friends

• Learn patience…remember our profession has brainwashed most of you and tried to make an art out of NOT acting like physicians


• You Become A Duck!

• Most importantly in your mind and then in your patient’s minds

• Patients refer like patients!

• Medical builds optical

• Optical builds medical


• First, to quote Dr. Craig…decide to be a modern eye doctor. A modern eye doctor treats allergies, abrasions, infections, ulcers, trauma, hordeola, glaucoma, retinal disorders or any other condition that walks into their office; performs minor surgery; takes care of their patients after hours

A modern eye doctor understands there is more to medical eye care than dry eyes and allergies


• NEXT, STOP GIVING AWAY YOUR EXPERTISE AND START CHARGING FOR PROFESSIONAL SERVICES LIKE OTHER PHYSICIANS DO


• Last, possibly most important, • learn the difference between a vision examination and a

medical examination


• Difference between vision and medical exam based on symptoms, signs and physician direction• What STARTS as a vision exam can turn into a medical exam•Medical exam is symptom oriented – no expected or routine

set of tests performed•Medical exam is “a la carte” – does not include refraction,

screening anything, or any additional testing (unless bundled)• LOTS OF TIME WILL BE SPENT ON THIS LATER TODAY

7/16/2016

14


•Medical exam is not limited to Medicare

• Self-pay (quit judging your patient’s pocketbook!)• Medicaid• Health Insurance

• STOP GIVING AWAY MEDICAL CARE!!!

Developing a FULL SCOPE Practice

1. Aptitude2. Attitude3. Access4. Accessories

APTITUDE• You already have most of it…what you don’t have is readily

available for you to learn

HINT 1: Review, educate

HINT 2: Genetic predisposition is not required

HINT 3: Use your lifeline…Call a friend!

• Few things go south by tomorrow…

• Invest in your ability to provide medical care

ATTITUDE• DOCTORS treat disease with medicine• DOCTORS order laboratory tests, x-rays, imaging studies• DOCTORS do surgery (of some sort)• DOCTORS touch patients• DOCTORS OBSERVE, DIAGNOSE AND TREAT• DOCTORS take responsibility for their patients in ALL ways

and at ALL times• DOCTORS MAKE MONEY FOR WHAT THEY DO!

Bad attitudes….• EFFECTS OF UNNECESSARY REFERRALS• If patients can’t count on you to take care of their infections,

abrasions, inflammations, glaucoma, cataracts and diabetic issues…they often won’t count of you to take care of their glasses and contact lens care• ONE patient lost from a stolen referral over five years costs

the average OD practice• $17,500.00

Access…Where Are The Sick Eyes• Over 50% of the population of the United States will enter

the ranks of Medicare within the next twenty years – 28% in the next 10 years• BUT….don’t be fooled, sick eyes are not just old eyes• Your largest source of medical care over the next ten years

will likely come from a younger to middle age population with just one disease • DIABETES

7/16/2016

15

Accessories (Technology) Do I need all that stuff to get started?

•Most likely…NO

• The Law of Incremental Gainput another way – “Walk before you run”

The big 4• To survive and thrive in the new world of medical

reimbursement, you MUST be prepared to handle THE BIG 41. Dry eyes2. Glaucoma3. Cataracts4. Diabetic eye disease

• Understand “when to hold ‘em and when to fold ‘em” –especially vitreo-retinal disorders

Walk before you run• The current street price for my toy box is about $480,000.00 • But that kind of investment in a young, growing, or

transitional medical practice doesn’t work•We can divide technology into:What can I do that costs little to NOTHING?What MUST I have?What would be nice to have?What is icing on the cake?

Sensorimotor evaluation (92060)•What is it?Medically necessary evaluation of a patient’s binocular

system based on complaints (diplopia, headache, asthenopia,

eye strain) that results in treatment and/or recommendations for

continued care• You are likely already doing this and thinking it is part of a

comprehensive eye exam – IT IS NOT

Sensorimotor evaluation (92060)•What equipment do I need?Occluder, phoropter, prism bars, stereotest, Maddox rod

– stuff you already have

• Capital Outlay ZERO

• This isn’t pushing the envelope…this is a standard of care issue

7/16/2016

16

Sensorimotor Reimbursement• Rare to see payment policy• Need order and interpretation/report• Can run in to denials based on “not a covered service”(only

some medical plans) but then the patient becomes the payer• Usually no problem w/ diplopia, strab, binocular vis disorder•Medical necessity usually must include an action plan

(besides “monitor”)• Usually reimburses at about $60.00

Gonioscopy (92020)•What is it?Medically necessary evaluation of a patient’s anterior

chamber angle and outflow system based on documented risk factor for glaucoma

• Sorry…dust the thing off. This is totally a standard of care issue!

Gonioscopy (92020)•What equipment do I need?Goniolens

• Capital Outlay $300-$400 (if you don’t have one already!)

Gonioscopy Reimbursement• Rare to see payment policy• Need order and interpretation/report• Obvious application to glaucoma but also ocular trauma, iris anomalies, growths, prior angle surgery

• Ant seg SLO is NOT gonioscopy and cannot be billed as such• Usually reimburses at about $35.00

Extended ophthalmoscopy (92225/6)

•What is it?Medically necessary, extended (not routine) evaluation of a patient’s posterior

chamber with additional, more extensive documentation of findings

•When is that? “evaluation of serious complications of the retina and

vitreous”. Flashers, RD, retinopathies, hemorrhages, holes, glaucoma


• Good news and a caveat• GOOD NEWS: Unlike photography, medical necessity based on the

NEED to look, not what you found. So unlike photography, CAN document nothing!

• CAVEAT: Be careful here…must be based on medical necessity to evaluate beyond routine ophthalmoscopy

7/16/2016

17


•What equipment do I need?Dilating drops, condensing lenses, BIO – stuff you already

have

• Capital Outlay ZERO

• Any downside here?time intense documentation and be careful of over-use

Extended ophthalmoscopy reimbursement

• Look for payment policies!Need orders and interpretation/report. Cannot bill with fundus photographySome policies say cannot use if photography can

document

• Usually reimburses at about $30.00

Treatment with contact lens (92071)

•What is it?Medically necessary application of bandage contact lens to assist in management / healing of ocular surface dz

• Applies To?Wounds, significant dry eye, corneal compromise (SPK) Be careful taking this too far! Do your patient a favor and STOP THE PAIN!


•What equipment do I need?Slit lamp, bandage contact lensCapital OutlayCost of bandage lens – usually zero

• Explanation: 92071 does NOT include the cost of the bandage lens

(like the old code), butcan only bill for YOUR COST of a REVENUE PRODUCT


• REIMBURSEMENT INFORMATION• Unusual to see payment policy• Need documentation of medical necessity – no mention of

interpretation and report• National edit with corneal foreign body removal• Unilateral code – use –RT, -LT• Usually reimburses at about $39.00 (forget the material

billing!)

Color Vision, extended (92283)•What is it?Medically necessary evaluation of color vision and color

matching in diseases that would effect the color perception system

• Applies To? Suspicion of color vision defects ESPECIALLY ACQUIRED optic nerve anomalieshigh risk medicationsvocational purposes

7/16/2016

18

Color Vision, extended (92283)• What equipment do I need?Farnsworth D-100, anomaloscope, digital color vision analysis

(ColorDx or equivalent)

• Capital Outlay$800-$1,300 (for digital system…forget the rest)

• CAVEAT: National reported frequency of 1:100,000 patient encounters This is mainly PRE-digital testing availability. 2014 and beyond frequency will be higher but accurate

application and documentation essential

Color Vision reimbursement• Congenital Color Vision Defects (Congenital CVD)• Deuteranopia 8% males; Protanopia 1% males – but is extended

color vision analysis necessary? DEPENDS• Acquired Color Vision Defects (Acquired CVD)• POAG: 30-50% tritanopia and 20-30% generalized loss• DR: tritan effects predict retinopathy and DME• Optic Neuropathy: Leber’s; AION; non-AION; MS• Medication SE: digoxin (CHF, A-fib); ethambutol, isoniazid (TB);

amiodarone (antiarrhythmic); methotrexate (RA, cancer); sildenafil etc (ED); oxymetazoline (decongestant); cisplatin (cancer); tamoxifen (breast cancer)USE IN ALL THESE RECOMMENDED BY NIH!

Color Vision reimbursement• REIMBURSEMENT INFORMATION• Rare to see payment policy• Need documentation of medical necessity and

interpretation and report• Bilateral test• Usually reimburses at about $58.00

Amniotic membranes (65779)•What is it?Amniotic tissue applied to cornea to aid in healing and

restructuring of tissue

• Applies To?Severe dry eye patientsRCEcorneal dystrophiessevere injuries

Amniotic membranes (65779)•What equipment do I need?Amniotic tissue, sterile field, a little practiceA freezer if using Prokera tissue

• Capital Outlay$600-900 per tissue sample (companies work with you!)

Amniotic membranes (65779)• Reimbursement Information• Expect new payment policies (again due to optometric

abuse)• Need surgical report• Obtain pre-certification from payer (no guarantee of

payment even then – companies will work with you)• Reimburses around $1,100 - $1,400

7/16/2016

19

VISUAL FIELDS (92083)•What is it?Medically necessary evaluation of retinal thresholds in

the central or peripheral retina

• Applies To?Too many to name – Jurisdiction H Medicare LCD lists

over 450 potentially applicable diagnosesPersonal Note: Visual field testing and analysis is a PITA but you cannot practice medical based eye care without this capability

VISUAL FIELDS (92083)•What equipment do I need?Threshold visual field instrument (see next slide)

• Capital Outlay Just depends (see next slide)

VISUAL FIELDS (92083)• Equipment PointersCANNOT manage disease with a standard FDT or most other

“screening” perimeters

• Is the HVFA still the “standard of care”

• OptionsHVFA 740/750i – the beast, most expensive by farOctopus – BIG interest in glaucoma circles (good bargain option)Humphrey Matrix – great idea but…Oculus Centerfield – great bargain performer

VISUAL FIELDS (92083)• REIMBURSEMENT INFORMATION• COMMON payment policy – but usually no big deal!• Bilateral test• Requires orders and interpretation / report• Charging for “repeat” testing• Usually reimburses $70-80

Anterior segment photography (92285)

• Applies To?Pterygia; pinguecula; scars, dystrophies, degenerations

effecting vision, lumps and bumps, iris trauma…could go on and on

•What equipment do I need?Options from high end video slit lamp systems to iphone

• Capital OutlayNone to $20,000

• REIMBURSEMENT INFORMATIONUsually reimburses $20-30

Fundus photography (92250)• Applies To?Again…too countless to name (but again…we will talk

about medical necessity this afternoon!)•What equipment do I need?Fundus camera

• Capital OutlayUsed market <$10k to OPTOS Daytona at ~$80,0000

• REIMBURSEMENT INFORMATIONMUST MEET MEDICAL NECESSITY REQUIREMENTS Reimburses $50-80

7/16/2016

20

Scanning laser (92132 /3/ 4)• Applies To?Countless vitreoretinal disorders; glaucoma; diabetic

retinopathy; macular degeneration; corneal misadventures; fitting scleral lenses

•What equipment do I need?Several great options! One here today

• REIMBURSEMENT INFORMATIONCOMMON payment policyReimburses $30-40

Corneal topography (92025)• Applies To?Surgical mis-adventures; contact lens mis-adventures;

congenital and acquired corneal dystrophies and degenerations; fitting of rigid and complex contact lenses

•What equipment do I need?Corneal topographer

• Capital OutlayHighly variable - $15K to well over $50K

• REIMBURSEMENT INFORMATIONUncommon to see payment policy Reimburses about $20

Punctal plugs (68761)• Applies To?Aqueous deficient dry eyes

• What equipment do I need?I do Smart Plugs

• Capital OutlayHIGH variability – buy in bulk and decrease

• Common payment policiesLOTS of documentationconfirmed aqueous deficiency dry eyeonly after traditional methods tried and failedReimburses around $150 for first plug, second decreased to

50%, third and fourth decreased to 37.5%

Electrodiagnosis (95930 / 92275)• Applies To?Glaucoma (mainly ERG); optic neuropathies; diabetic

retinopathy (ERG); AMD; unknown vision reduction/loss (ultimate malingering test) – when you need it, it is invaluable

• What equipment do I need?Diopsys NOVA System (Here today)

• Capital Outlay$33,000

• REIMBURSEMENT INFORMATIONReimburses about $125

So let’s try to summarize

this

PROCEDURE MUSTHAVE

CONSIDER ICING COSTNEW

USED

Sensorimotor evaluationYES ZERO N/A

Gonioscopy YES $0-350 N/A

Extended ophthalmoscopy YES ZERO N/A

Treatment with BCLYES ZERO N/A

Extended color vision testing YES $1200 NO

Visual field YES YES

Specular microscopyYES $25K ???

Fluorescein angiographyYES A TON YES

7/16/2016

21

PROCEDURE MUSTHAVE

CONSIDER ICING COSTNEW

USED

Punctal plugs YES ZERO N/A

Fundus photo YES $10-80K YES

Anterior photo YES $0-8K YES

Scanning laser YES YES NO

Corneal topographyYES $0-15K+ YES

Amniotic membranesYES

ZEROKINDA N/A

Electrodiagnostic(VEP / ERG) YES $42-62K YES

Glaucoma diagnosis• Estimated to affect >3 million Americans (only half know)• Identify the risk factorsAfrican-American ethnicity Female genderA positive family history of glaucoma Advanced ageIncreased optic cup sizeIOP greater than 22mm HgNotches in the rim and compromised nerve fiber layer.Refractive error (myopia for most, hyperopia for PACG, OHT)Systemic disease (Vasospasm, Atherosclerosis, Episodes of

acute hypotension, Systemic hypertension, Diabetes)

Glaucoma testing• Gather the appropriate data:Patient historyMultiple IOP readings at various times of the day; Gonioscopy (more on that in a minute)Visual fields (with solid reliability indices) Multifocal electro-retinogram (ERG); Digital photography, Nerve fiber layer thickness; and Central corneal thickness

Glaucoma medications• Don’t be afraid to prescribe• 82% of prescribers are NON-EYE CARE PRACTITIONERS!• Lots of optionsAlpha AgonistsBeta blockersCAIsMioticsCombinations

• Prostoglandin analogs safe, effective, well tolerated

Age Related Macular Degeneration

• Risk factorsAgeRace

• Modifiable risk factors Smoking, lower intake of dietary antioxidants and Omega-3 fatty acidsHigher body mass index (BMI)

• SignsDrusenstructural and functional changes

ARMD Detection & Diagnosis• BasicsDilation (extended ophthalmoscopy)Photography Contrast sensitivityAmsler Grid

• RecommendedOCTERG

• OtherPreferential hyperacuity perimetry (PHP)Genetic testing (signs of age-related changes) FAF

7/16/2016

22

ARMD Treatment• Rotterdam study• Age-Related Eye Disease Study• Options for NutraceuticalsStock the supplements you frequently use and have

patients purchase them directly from you. Alternatively you can prescribe a particular product for

the patient, have them call a designated phone number to order, and get a professional fee from the manufacturer Prescribe a specific brand available at a local grocery

store, pharmacy, etc

ARMD and your practice• Dr. Dunbar“It's going to overwhelm retinal specialists, and these

patients can often be managed in the optometric practice. For that to happen, optometrists need to acquire the necessary skills and tools to gain that confidence”

• Dr. Shechtman “I also think it's a matter of having the right diagnostic

tools. I could feel pretty confident looking at a retina, but if I don't have an OCT in my office, it may be a bit more challenging to properly manage the patient.”

ARMD and MPOD•Measuring macular pigment optical density (MPOD) may be one way to help gauge risk of developing AMD. Macular pigment helps protect the photoreceptors from

oxidative stress of UV and blue lightIn general, the more dense the MPOD, the “healthier”

the macula. • Several commercially-available instruments. Two most common: Quantifeye (Zeavision) and the

Macuscope (MarcoNumbers of users growing

ARMD and MPOD• Can be measured over time to gauge effectiveness of treatment• Improvement of MPOD is likely to improve visual functionA low MPOD score is considered to be below 0.21, moderate falls between 0.21 and 0.44, and high is 0.45 or above.

• For patients with low MPOD, usual therapy is dietary modification and/or vitamin supplementation. Increased intake of the carotenoids lutein and zeaxanthin

improves MPOD scoresCarotenoid-based, eye-specific supplement or Eat plenty of spinach, kale and/or broccoli every day

Diabetes• CDC estimates 40% of all American adults will be affected • Of these, 28.5% are diagnosed with DR, DME or both• Equals more than 8 million Americans• Two primary factors affecting development / progression

1. Disease duration and 2. Metabolic control of diabetes are the

DR Detection & Diagnosis• Even retina specialists may fail to detect cases of early NPDR• This makes a strong case for use of digital retinal photography and

red-free viewing to increase detection of subtle changes. • Approx 30% of patients with NPDR have retinal abnormalities

outside the posterior pole• Must examine the mid-peripheral and peripheral retina for

retinopathy in every patient with known or suspected diabetes (ultrawidefield imaging helpful)• Patients w/ NPDR lesions in periphery (outside standard ETDRS

fields)3.2X more likely to have a two-step worsening and4.7X more likely to progress to PDR within 4 years

7/16/2016

23

DR Detection & Diagnosis• Watch for ophthalmic symptoms and signs Refractive fluctuation, ocular surface disease, recurrent staphylococcal lid disease, dermatologic changes like acanthosis nigricans and, of course, unexplained retinopathy.

• In-office screening tools for undiagnosed diabetes like that available from Weill-Cornell Medical College• New technology to measure advanced glycation endproducts

(AGEs) in the crystalline lens• In-office measurement of blood glucose Any random blood glucose value >100mg/dl, increase the risk

of undiagnosed DM 20X

DR Therapy• New Diabetes MedicationsGlucagon-like peptide-1 (GLP-1) analogs, Byetta and Bydureon

(exenatide, AstraZeneca) Victoza (liraglutide, Novo Nordisk) and Trulicity (dulaglutide, Eli Lilly) are injected, non-insulin medications that not only lower A1c but also promote weight loss and may reduce cardiovascular risk.Dipeptidyl peptidase-4 (DPP-4) inhibitors are oral medications that

block the enzyme that degrades endogenous GLP-1, but don’t cause weight loss. Januvia (sitagliptin, Merck), Onglyza (saxagliptin, AstraZeneca) and Tradjenta (linagliptin, Boehringer IngelheimPharmaceuticals) are examples of DPP-4 inhibitors.Sodium glucose transporter-2 (SGLT2) are oral agents that prevent

re-absorption of serum glucose in the kidneys, thereby promoting urinary excretion as well as weight loss and reduction in blood pressure. Examples of SGLT2 inhibitors include Invokana(canagliflozin, Janssen Pharmaceuticals) and Farxiga (dapagliflozin, AstraZeneca).

DR Follow up• Focus on Control of diabetes & prevention of retinopathyEarly detection of DR and especially STR with timely referral for appropriate treatment

•Must understand Diagnosis Treatment protocol

•Must coordinate with other physicians Send reportsSecure our position on care team

Nutraceuticals• Consumers more interested in good nutrition and it’s link to

healthy vision is not being ignored by

• U.S. nutraceuticals market est to be $75.3 Billion by 2017

• Options for NutraceuticalsStock the supplements you frequently use and have patients

purchase them directly from you. Alternatively you can prescribe a particular product for the

patient, have them call a designated phone number to order, and get a professional fee from the manufacturer Prescribe a specific brand available at a local grocery store,

pharmacy, etc

Prescribe Nutraceuticals• A specific product recommendation by you can be helpful,

but may not be available or may be difficult to find• Carrying products in the officeConvenient for patientsEnsures patient compliance

•Without specific guidelines from the youpatients will likely buy wrong product or something of lesser quality orwith levels of nutrients that are simply not effective

Nutraceuticals Financial Impact•MBA estimates that increasing revenues by selling only an

additional $10 in nutraceuticals per complete eye exam could add $22,000 per year to a practice’s revenue.

• According to Laurie Capogna, OD, author of two books on “Eyefoods,” if an ECP retails a three-month supply of supplements to

three patients per day, it could lead to $15,000 per year. If a patient returns to to purchase another 3 month

supply, can add $30,000 extra profit per year

7/16/2016

24

Nutraceuticals – getting started• Educate patients that ARMD comes from nutritional

deficiencies • Pick a company that has a reputation of building its products

based on science with high-quality ingredients If people walk in discount stores and pick the cheapest

one, they will get what they pay for •Move slowly and methodically in order to become an expertIt will take some study and commitmentKnow the biochemistry and purpose of any supplement

before committing to carrying

Specialty RGPs• Scleral Lenses are beneficial for severe ocular surface disease and Alleviation of debilitating symptoms of severe dry eye

• Scleral lenses are advantageous toprotect, lubricate, diminish pain, reduce ocular symptoms, and support the ocular surface.

Uses of Scleral Lenses• Keratoconus• Keratoconjunctivitis Sicca• Exposure keratopathy• Graft-versus-host disease (GVHD), • Stevens-Johnson syndrome, or • Limbal stem cell deficiencies

Scleral lens Reimbursement• Policies vary, but many VCPS cover• Cost vary widely can be as high as $4,000 per eye or more• Set the lens cost to cover material cost, shipping, staff costs for lens verification,

scheduling, return costs, restocking fees and a small profit margin.

• “If you keep your profit in your professional fees, then you'll do right by your practice and your patients.” - Clark Newman

Orthokeratology• Several studies have been conducted that address safety of Children's Overnight Orthokeratology Investigation (COOKI, Walline,

2008), Longitudinal Orthokeratology Research in Children (LORIC, Cho et al,

2005), Corneal Reshaping And Yearly Observation Of Nearsightedness

(CRAYON, Walline, 2008), Stabilizing Myopia by Accelerating Reshaping Technique (SMART,

Eiden et al, 2009), Overnight Corneal Reshaping (OCR, Lipson, 2009), and A study conducted at The Ohio State University (Bullimore, 2009).

• Each suggests that under controlled circumstances, Ortho-k is safe. • COOKI and CRAYON studies concluded 75%of children are candidates

Orthokeratology• It is not a new concept - dates back to the 1940s• Earliest ortho-k techniques simply used keratometry measures and clinical judgment

• In early 1990s with topography and new GP materials it a more viable mainstream treatment option • Compresses the corneal epithelium, forcing a reduction in central corneal thicknessonce removed, the cornea slowly returns to its natural

statecompressed effect should persist for at least 12 -15 hours

7/16/2016

25

Orthokeratology• Many initially suggested that ortho-k lenses could be used to

control or even halt myopia progression. • In 2004, COOKI researchers determined that overnight ortho-k

was both a safe and effective treatment for curtailing myopia progression.• In 2005, LORIC also indicated that ortho-k was effective at

controlling childhood myopia• 2008 CRAYON subjects experienced significantly less annual

change in axial length and vitreous chamber depth• 2009, SMART subjects wearing ortho-k lenses exhibited a mean

progression of 0.00D, compared to an average of 0.50D in the control group.

Orthokeratology Reimbursement• Normally, orthokeratology is non-covered service• Ortho-k prices fees range from $1,000 to $2,000 • Additional fees for replacement ortho-k lenses, lens care solutions, and follow-up exams range from $300 to $500 /year

• In order to maintain the long-term effect of ortho-k, the patient must wear a retainer lens.

Dry Eye Diagnosis & Testing• Prevalence varies, but around 15%• Testing includesTear analysis (MMP-9) Meibomian Gland Imaging (dropout, blockage, blink rate,

lipid layer thickness)Meibomian gland expressionTear meniscusTBUTStaining (conj, cornea) sodium fluorescein, rose bengal,

and lissamine green

Dry Eye Dye Testing• Fluorescein stains defects in the corneal and conjunctival epithelium,.

• Rose bengalstains dead conjunctival cells or cells unprotected by the normal

mucin layer. stains the conjunctiva more than it stains the corneacorrelates with the degree of aqueous tear deficiency, TBUT, and

reduced mucus production by conjunctival goblet cell and non-goblet epithelial cells. may irritate, and be toxic to, the ocular surface

• Lissamine green similar mechanism as rose bengal does; however, it is less irritating

Dry Eye Tear Production Testing• Schirmer’s test used to evaluate aqueous tear production with a special filter paper

(no. 41 Whatman) that is 5mm wide and 35mm long. Schirmer 1 is performed without anesthetic, and Schirmer 2 is performed with anesthetic. In theory, both evaluate baseline secretion

• Phenol red cotton thread testtakes 15 seconds per eye, and no anesthetic is needed. color change in the cotton thread can be confirmed hours after

testing• Fluorescein clearance testThis test may be more accurate; however, it is rarely performed measures the clearance of 5mL of 2% NaFl instilled into the eye. Then, after 15 minutes, the color of the lateral tear meniscus is

evaluated using fluorophotometry and is matched to a scale.

Dry Eye Diagnosis & Testing• Matrix Metalloproteinase-9 (MMP-9) DetectionInflammaDry (Rapid Pathogen Screening, Inc.) similar to an at-home pregnancy test takes a sample of a patient’s tears and gives a positive or

negative result in 10 minutes.More than 40ng/mL of MMP-9 indicates a positive

InflammaDry test.• MMP-9 A proteolytic enzyme secreted from stressed epithelial cells on

the ocular surface (a non-specific marker of inflammation)Correlate with dry eye, OSD, and some clinical findingsAssociated in both Sjögren’s and MGD

7/16/2016

26

Dry Eye Diagnosis & Testing• Tear Osmolarity

important for many aspects of epithelial and nerve cell function. In healthy tears, the electrolyte concentrations are maintained to ensure correct osmolarity. unhealthy tears, proteases are activated, degrade the extracellular matrix and the tight

junctions between adjacent cells of the corneal epithelium. Activated proteases are responsible for cleavage of cytokines into an activated

pro-inflammatory form. A subsequent increase in electrolyte concentration increases tear osmolarity. Elevated osmolarity can cause less regulation of the tear film, more damage to the ocular

surface, and more inflammation. Increased rates of tear evaporation lead to a more concentrated tear film (increased

osmolarity). Increased tear evaporation is present with both aqueous deficient and evaporative dry eye

disease.• The TearLab Osmolarity System (TearLab Corporation)

measures the osmolarity of the tears and, a 50nL sample of tears is taken in vitro for diagnostic use.The system utilizes a temperature-corrected impedance measurement to provide an indirect

assessment of osmolarity. Osmolarity values above 308mOsms/L are generally indicative of dry eye disease.

Dry Eye Diagnosis & Testing• Corneal TopographyNon-invasive assessment of tear meniscus height. An indicator of ocular surface tear volume.

• Analyzes the reflected Placido ring mires and measures the TBUT throughout the surface, Breakup times of greater than 14 seconds are considered normal. Between 13 and 8 seconds are considered borderline. 7 seconds and below are considered abnormal.

Dry Eye Medications & Follow up• Patients are symptomatic and looking for someone to help• Huge potential for your practice•Medication optionsTopical Cyclosporine Steroids

• Give them an OTC recommendation and you might as well give them a referral to your colleague down the road• Actual treatment requires follow up (and you can bill for it!)• Patients will appreciate it and refer others

Dry Eye Supportive Therapy•Warm compress is a necessity for nearly every patient that

suffers from both MGD/OSD. increased compliance when purchased from the practice

• Lid hygiene is an important part of treatment increased compliance when purchased from the practice Foam lid hygiene product in the shower Lid scrubsHypochlorous acid for more stubborn blepharitisDemodex is often controlled by a take-home product

Dry Eye In office Therapy• Lid debridement, •Micro exfoliation • Thermal pulsation of the meibomian glands.• The concept is that removal of biofilm on the lids is no

different than the removal of biofilm between the teeth and the gums that has resulted in so much decrease in inflammation in dentistry.

Plan for your Practice

• It wont happen overnight• Think about what works for you• Implement 1 or 2 things at a time•Always work to improve your practice

7/16/2016

27

The results may be surprising

[email protected]

billing and coding for maximum reimbursementtexas.aoa.org/documents/tx/2016 pcs/handout - morning...

Documents