An in-depth look at glaucoma practice.
Three experts share their own separate approaches to running a glaucoma practice. Read their insights into how to start a glaucoma practice, how to code for glaucoma and the value of the new Ocugene test for predicting who will develop the disease.
Sorting Through the Nuts and Bolts of a Glaucoma Practice
Prepare yourself for a challenging and rewarding specialty.
BY ERNEST L. BOWLING, O.D., M.S., F.A.A.O., Summerville, Ga.
Diagnosing and treating glaucoma within a primary care practice is one of the most challenging and rewarding aspects of optometry. Forty-six states plus the District of Columbia currently allow optometrists to manage the disease, yet many O.D.s still refer their patients to other providers for this important service.
These next few accounts will explain how to assemble the nuts and bolts of a glaucoma practice within your current operation so you don't have to send patients away. I'll give you the basic information that you need to get yourself started.
Before launching your own glaucoma practice, take as much continuing education on glaucoma as you can, from as many different lecturers as possible. Visit a glaucoma practice and pick the specialist's brain; see how folks who do this for a living handle the disease. Then look into equipment.
Prepping your office
If you're going to treat glaucoma, you'll need a sphygmomanometer and stethoscope for monitoring patients' blood pressures. You also must invest in the following:
An applanation tonometer. This is the standard of care for glaucoma, so the instrument is vital for managing the disease.
Some form of threshold visual field testing device is critical, and several are available. Once thought the most sensitive way to detect glaucoma, visual field testing is now considered more of a tool for tracking the disease than for detecting it.
A gonioscopy lens. This lens is necessary for evaluating the anterior chamber angle. Several types are commercially available, but the type isn't nearly as important as your ability to use it and be comfortable with what you're seeing.
Some means of evaluating the optic nerve head. The direct ophthalmoscope forces you to use color differences to estimate the edge of the cup and can lead you to underestimate the true cup size. Slit lamp ophthalmoscopy with a condensing lens is probably the best way to assess cup-to-disk (C/D) ratio. While many O.D.s prefer the 90D-condensing lens, a better option for glaucoma patients is the clear 78D or 60D lens.
Some means of quantifying the optic nerve. Stereoscopic fundus photos have long been used, but with the advent of optic nerve and nerve fiber layer imaging technologies, we now have a variety of optic nerve and nerve fiber layer imaging technologies.
|The Benefits of a
Glaucoma management raises your patient's level of expectation and comfort with your service. It's also financially beneficial for your practice. Glaucoma patients are among the most loyal in a practice and can generate a tremendous number of referrals from family and friends, not only for routine eye care, but also for treating ocular disease. And through proper third-party coding and billing, glaucoma generates another revenue stream besides that for routing eye exams and contact lens evaluations.
Co-manage a big investment
Purchasing these devices may be cost prohibitive for your practice. If so, consider co-managing these patients with your glaucoma specialist. We send our patients out to co-managing glaucoma specialists for retinal tomography and unbundle the procedure code -- the specialist's office bills for the technical component and our office bills for the professional component.
Making the diagnosis
If you suspect glaucoma, you'll need to establish baseline values for the patient before initiating therapy. Perform a comprehensive ocular examination, including the following:
Complete history with review of symptoms. The first, and perhaps most important, step in the exam is a thorough case history, which should include questions about these issues:
- Demographics. Both age and race are risk factors for glaucoma, with elderly African-Americans having the highest incidence, according to the Baltimore Eye Survey of August 1991.
- Heredity. A family history of glaucoma, especially on the maternal side, is considered a risk factor.
- Past trauma. A past history of trauma may contribute to elevated intraocular pressure (IOP) later in life.
- Medication use. Past or current use of topical or oral steroids may cause elevations in IOP levels. Medications commonly used to control hypertension, such as oral beta-blockers, can lower
- Refractive status. Low-to-moderate amounts of myopia are often associated with pigmentary dispersion syndrome, and high myopia in particular has been associated with a higher incidence of glaucoma.
Physical exam with IOP assessment. The first hands-on step in any glaucoma work-up is biomicroscopy, which yields a wealth of information about the eye's efficiency in draining aqueous. Be sure to look for:
- Pigmentary deposits. Usually in the form of a Krukenberg's spindle, these deposits indicate pigmentary dispersion syndrome (PDS). Small white flakes at the edge of the pupil and large sheets on the lens capsule indicate pseudoexfoliation syndrome (PXS). The debris from either condition can temporarily clog the trabecular meshwork, causing episodic rises or "spikes" in
- Uveitis. Active anterior segment inflammation can cause an increase in IOP. Patients who have active uveitis may have increased IOP, which usually returns to normal once the uveitis resolves.
- Pupil or lens abnormalities. Look closely for evidence of trauma. An afferent pupillary defect may also mean that the glaucoma is more advanced in one eye than in the other.
- Narrow angles. Most optometrists routinely screen all patients for narrow angles using von Herrick's technique. However, any time you suspect glaucoma you should perform:
- GONIOSCOPY. This test rules out a recessed or anatomically narrow angle not detected by other techniques. Also, you should gonioscopically examine the angle in any diabetic who has elevated IOPs to rule out
- DILATED FUNDUS EXAM WITH DISC ASSESSMENT. The most important factor in diagnosing glaucoma is evaluating the optic nerve. Stereoscopic evaluation of the optic nerve using a 90D, 78D, 60D or fundus contact lens is the best method for evaluating the optic nerve.
- FULL QUANTITATIVE VISUAL FIELD ASSESSMENT. Experts once believed this was the definitive test for glaucoma because so few patients who had elevated IOP ever developed field loss.
However, up to 20% of the optic nerve can atrophy before automated perimetry can detect a field defect. This test requires a learning curve, and first-time visual field patients often exhibit an initial field defect that disappears on follow-up tests. And some patients can't perform reliable, accurate visual field tests no matter how many times they try.
Because glaucoma is a disease of the optic nerve, it's important to carefully examine the optic nerve for signs of neuropathy. These signs include:
- notching or thinning of the superior or inferior neural rim tissue
- disc hemorrhage
- nerve fiber layer loss
- peripapillary atrophy.
One of the more typical patterns of glaucomatous damage to the optic nerve is a vertical enlargement of the C/D ratio. Thus, a large C/D ratio can suggest glaucoma damage.
While we can often see on initial examination that the patient has a problem, it's the covert cases that give us sleepless nights and clinical frustrations. For example, most patients who have elevated IOPs don't develop glaucoma damage to their optic nerves. About 20% of glaucoma patients never exhibit an IOP reading greater than 21 mm Hg.
Traditionally, the first line of treatment for glaucoma has been reducing IOP through topical medical therapy. If the medications fail to reduce IOP and stabilize the disease, the next line of defense tends to be argon laser trabeculoplasty (ALT). Filtration surgery is generally reserved as a last line of defense.
Some O.D.s prefer to begin therapy with a beta blocker, adding a second medication (usually a prostaglandin analog or alpha agonist) if the target pressure isn't achieved. A recent survey showed that nearly 40% of O.D.s begin new patients on prostaglandins.
Another useful strategy involves substituting medications rather than adding another medication. Maximum medical therapy (MMT) is usually two medications. Treatment depends on several factors:
- the patient history
- contraindications for certain medical therapies
- medication schedule
Know what area pharmacies charge for glaucoma medications. Calling local pharmacists can yield this information.
Keep a chart of medication costs posted on the exam room wall. If cost is an issue, consider an ALT, which may reduce the need for multiple drops. Some pharmaceutical companies have indigent care programs that provide medications free of charge. Contact their sales reps for information about these programs. At the initial visit, tell the patient about possible surgical interventions that you might recommend should MMT fail to achieve control.
Establishing follow-up visits
One big problem we face, especially when we first begin managing glaucoma, is establishing proper intervals between visits and scheduling follow-up visits appropriately.
Consult an accepted, published guideline such as the AOA's Optometric Clinical Practice Guideline: Care of the Patient with Open Angle Glaucoma. But don't let inexperience or unfamiliarity with the disease and its treatment turn you into an "overutilizer." Billing a patient or his insurance for extra visits because you're not yet comfortable managing the disease isn't right and can increase your chances of being audited. Many offices use a "flow sheet" in the patient's record to show when ancillary tests were last performed. This ensures that a patient doesn't go too long without proper testing.
"I didn't take my medicine because . . ."
The reasons patients fail to comply with their glaucoma treatment vary, so there's no one-size-fits-all solution. The patient often doesn't see a benefit from therapy, the cost may be prohibitive and, let's face it, no one likes to go to the doctor. From the beginning, it's imperative to educate the patient regarding his diagnosis, treatment plan and need for regular follow-up visits.
Try to address possible non-compliance issues at the time of your initial diagnosis. See what social issues the patient may have (cost of the medication, impaired ability to follow directions, etc.) and address them.
Document missed follow-up appointments in the patient's chart. The office staff should attempt to follow these patients up and reappoint them. They should bring glaucoma no-shows to your attention. Any eventual decision to refer the patient for surgery may arise from compliance issues. Sometimes, the mere thought of surgical intervention may be enough to motivate the patient to comply with your directions.
Like learning to crawl
Glaucoma diagnosis and management in a primary care practice can be likened to learning how to get around -- you have to crawl before you can walk before you can run. Begin your glaucoma practice with cases you feel comfortable with. As Clint Eastwood once said, "A man has to know his limitations."
"Optometrists can manage the majority of glaucoma cases at the primary care level. Just as internists can treat the majority of diabetes cases but must refer a few difficult cases to endocrinologists, so must O.D.s occasionally refer difficult, advanced cases to glaucoma specialists, " says Michael D. Brown, O.D., F.A.A.O., of the Huntsville (AL) VA Medical Center. "Don't punt too quickly if the first medicine or two doesn't work. It usually takes a long time to go blind from glaucoma. Most cases are not 'hot potatoes' that must be unloaded quickly."
Don't feel like you're letting the patient down by co-managing with a specialist. Indeed, let him know you're attempting to provide the best care you can, and that as the primary eye doctor, you want to be in the loop and will monitor his condition and progress throughout the entire process. As your experience and comfort level grow, begin to take on more complex cases. Start small and build over time. Then seek out other medical caregivers and let them know of your desire to care for glaucoma patients. You'll be providing total care for your patients, which is the goal of a primary care optometrist.
References available upon request
Dr. Bowling practices in northwest Georgia. He's a member of Optometric Management's editorial board, a multiple recipient of the AOA Optometric Recognition Award and is a clinical examiner with the National Board of Examiners in Optometry.
Comprehensive Guide to Billing for Glaucoma
Here's how to get a handle on a
coding and billing challenge.
BY JOHN W. LAHR, O.D., F.A.A.O., Cambridge, Minn.
As you know, glaucoma is a lifelong illness that we can control and manage, but not cure. Glaucoma "forever" patients require many professional services, including comprehensive examinations, office services, visual field testing, fundus photography and other more specialized tests at differing intervals. Treatment services added to diagnostic services can present a coding and billing challenge for you.
An estimated 6 to 7 million patients have diagnosed glaucoma worldwide, and an equal number of people are suspected to be undiagnosed or to have become non-compliant with therapy. To address the problem, Medicare created a new screening code to encourage people to seek early detection and treatment. The only problem for many O.D.s and their administrative staffs is how to properly and effectively code and bill for the services provided. Here, I'll help you get a grip on this issue.
Coding for exams and services
Patients who are suspect for glaucoma or have been diagnosed with the disease require a comprehensive exam that's coded as a 92004/92014 or as one of the Evaluation/Management (EM) codes 99203/99204/99205/99214/99215 depending on the history, exam and medical decision making required.
For coding and reimbursement, it's important that you recognize that a new patient is one who hasn't received any professional services from you or another physician of the same specialty who belongs to the same group within the past 3 years. Also, remember to bill the refraction (92015) separately, as this isn't included in the definition of any ophthalmological or office service code.
Most glaucoma patients and suspects are evaluated at different time intervals between comprehensive services. The American Optometric Association's Clinical Practice Guidelines specifies the recommended intervals.
Patients who require special ophthalmological testing, as defined in CPT 2002, are usually scheduled to return for these evaluations within a few weeks of the exam. Special circumstances, such as limited transportation availability, may require that you perform these tests on the same day as the comprehensive service. However, many patients are too fatigued to perform well on a threshold visual field and sit for other tests. It's better to schedule a separate date for these types of evaluations.
You can bill the office service component of these visits using the intermediate code 92012 or EM codes 99212/99213/99214/99215. The established patient codes are listed, assuming that a professional initially saw the patient for a comprehensive examination.
Evaluate each visit to ascertain how the service relates to the code definition and/or the history, examination and medical decision making required.
Understanding special ophthalmological services
These services are defined as "separate procedures that provide valuable diagnostic information to assist in determining if a patient has glaucoma or the progress and subsequent management of the disease."
Some tests are billed unilaterally, but most are specified as bilateral. Let's review the special tests that you can and often should perform. Each procedure is considered a bilateral or unilateral test for billing purposes. The Medicare national average reimbursement for 2002 is cited in parentheses and italics.
Gonioscopy (92020). This test determines whether a patient's anterior chamber angle is open or narrow, the type of glaucoma and the best treatment options. You may need to repeat gonioscopy to recognize changes with treatment over time and to evaluate the effectiveness or adverse outcomes of glaucoma surgery. Gonioscopy is generally appropriate at the initial diagnosis and later in the treatment and management if changes are suspected because of treatment or progression of the disease. Bilateral ($48.14)
Serial tonometry (92100). This constitutes a series of intraocular pressure (IOP) measurements over a day to determine the diurnal variation in a patient's readings. Opinions suggest that deviations (high measurement to low) of more than 6 mm may indicate a greater risk for glaucoma. The greater the variation, the higher the likelihood of the nerve damage and visual field loss.
A minimum of three readings is usually required to qualify for reimbursement. Serial tonometry is generally appropriate at the initial diagnosis. Bilateral ($61.18)
Visual fields (92081/92082/92083). An integral component of glaucoma diagnosis and treatment regimens, visual field analysis provides an analysis of the integrity of the nerve fiber layer. Current opinions suggest that you shouldn't require the presence of a threshold field defect before initiating treatment.
Reimbursement is currently higher for the screening field (92081) than it is for an intermediate (92082) or threshold (92083) field. This is an aberration because of a relative value expense review of the two higher codes and a failure to review the lower 92081. Optometrists and ophthalmologists have reported this imbalance, which the Relative Value Update Committee will probably adjust in the future. Don't bill the higher-level visual fields as 92081 to secure the small gain in reimbursement. Always bill the most appropriate code for the procedure perform-ed, as follows.
- 92081- A visual field such as a tangent screen, using a single isopter. Bilateral ($80.36)
- 92082- An intermediate examination using two isopters. This would be a separate field analysis not performed at the time of the comprehensive examination. Bilateral ($47.42)
- 92083- An extended field examination using three isopters such as 30-2 or 24-2. Often used annually to determine the effectiveness of the glaucoma treatment. Consider adjustments to the regimen if the defect worsens. Threshold visual field tests are generally performed yearly and may be used biannually in some cases. Bilateral ($73.48)
Scanning computerized ophthalmic diagnostic imaging (92135). This newer code reimburses for tests such as nerve fiber analysis, retinal tomography, ocular coherence tomography and retinal thickness analysis performed to determine integrity and/or thickness of the nerve fiber layer.
Most of these tests are used initially to determine a baseline for comparison with normal values to assist in the initial diagnosis. Later, this test provides a measure of ongoing thickness stability or change and determines treatment effectiveness. Imaging is less valuable or appropriate for severe or end-stage patients with minimal visual field remaining.
Imaging analysis is generally provided annually during the progress of the disease until patients reach end-stage glaucoma. Unilateral ($66.97)
Ophthalmoscopy -- extended with retinal drawing (92225/92226). As the name implies, this code requires ophthalmoscopy that extends beyond the normal dilation component of the comprehensive exam. Use drawings as well as interpretation and report. This code is often overused, and payers may track it.
Some payers don't list this code as payable with a diagnosis of glaucoma. The initial service is coded as 92225, and subsequent evaluations as 92226. If extended ophthalmoscopy is listed as a reimbursable code with a glaucoma diagnosis, an annual evaluation is generally performed. Unilateral ($22.24/$20.27)
Fundus photography with interpretation and report (92250). Fundus photography is a method by which to compare and track changes in the posterior pole. It can assist you with treatment and management decisions.
Fundus photography requires interpretation and you must maintain a report in the patient record. You may repeat this test to confirm stability or detail variation in structures. Fundus photography is generally used on an annual basis for comparison. Bilateral ($66.24)
Pachymetry (0025T). Measurement of corneal thickness is emerging as a valuable tool in analyzing the "true IOP." Based on the applanation tonometry formula, thicker corneas will produce higher IOP readings than thinner corneas.
The code is designated as Class III, which means it's a temporary code for emerging technology and may become
permanent in the future. A carrier may recognize it for tracking and data collection, and it could be reimbursed at the carrier's discretion.
If you perform pachymetry, bill code 0025T to help the carrier track the use and value. You should provide an interpretation and report in the patient record. Bilateral (This fee varies).
A Sample Year of Glaucoma
Diagnosis and Treatment Initiation*
Comprehensive Examination (-92004)
Refraction (-92015) $ 15.00
Office visit for extended diagnostic testing (-99213)
Gonioscopy (-92020) $ 41.14
Serial Tonometry (-92100)
Threshold Visual Field (-92083) $ 73.48
Fundus Photography (-92250)
Nerve Fiber Analysis (-92135-26-RT)
Nerve Fiber Analysis (-92135-26-LT)
6-month office evaluation (-99213)
*Note for the tables on pages 69 and 70: Each patient is different and may require more or fewer evaluations and testing. Your fees may
Modifiers provide the means by which you indicate that you've performed a service or procedure, yet altered it without changing its definition or code. Consider several modifiers for glaucoma coding and billing:
- RT and LT (right and left) designate which eye you tested. Use them when you perform a unilateral test. Bill on separate lines of the form.
- Use -25 for a significant, separate, identifiable E/M service by the same professional on the same day of the procedure or other service. This code is used when a patient's condition required a separate test or procedure above and beyond the initial service provided that could be related to the symptom or condition that prompted the initial visit.
- Use -26 when reporting the professional area of a procedure that is a combination of technical and professional components.
- Use -50 (bilateral procedure) for unilateral procedures where you test both eyes or perform procedures on the same day.
- Use -51 when you perform multiple procedures/services (other than E/M) at the session. List the most significant procedure first, with all other procedures listed with the -51 modifier.
- Use -55 for postoperative management only.
- Use -57 for an E/M service that resulted in a decision for surgery.
- Use -59 (distinct procedural service) to report that a procedure or service was distinct or independent from other services you performed on the same day. It's valuable for reporting multiple tests performed at the same visit such as 92020, 92100 and 92083 on the same service day.
- Use -78 (return to the operating room) for a related procedure during the post-op period.
- Use -79 (unrelated procedure or service by the same physician) during the post-op period to report the need to provide a service or procedure that's unrelated to the original procedure.
- Many special ophthalmological procedures are listed as a total fee but can be divided into two components. One described above is the professional component (-26), which is the analysis and interpretation; and the technical component (-TC), which includes the cost of the instrument and staff to perform the testing.
An example of where this is commonly applied is the scanning computerized ophthalmic diagnostic imaging (-92135). If you refer a patient to an ophthalmologist or another optometrist for this test, the office that has the instrument and performs the test would bill 92135-TC with the RT or LT for each eye and receive $47.78 per eye.
The optometrist would bill 92135-26 with RT or LT for each eye and receive $19.19 per eye in addition to the office service code billed for the rest of the visit to determine the overall treatment/management plan.
Currently, codes 92081-83, 92135 and 92250 may be divided, with -26/-TC modifiers for glaucoma patients.
Changes in screening services
The year 2002 marked a shift in Medicare policy. Screening codes were approved to encourage high-risk individuals to seek testing and early intervention for glaucoma.
High-risk individuals are defined as "those with a family history of glaucoma, patients with diabetes and African Americans over age 50 covered by Medicare." Individuals with glaucoma risk factors are entitled to a screening once every 12 months. It must include the following:
- history that shows risk factors for glaucoma (age over 50, African American, family history, trauma, steroid use, etc.)
- visual acuity
- IOP and applanation tonometry
- dilated retinal exam
- direct ophthalmoscopy
- slit lamp biomicroscopic examination.
The codes you should use for billing are Health Care Procedural Coding System (HCPCS) category listings G0117 "Glaucoma screening by physician for high risk patient," which the Medicare national reimbursement lists at $52.13; and G0118 "Glaucoma screening under direct supervision of a physician," which reimburses $36.92.
A point to consider is the delegation and supervision of a dilated retinal examination, which may practically limit the screening to code G0117. The only diagnosis code that will drive the reimbursement for G0117 or G0118 is V80.1. (V80.1 is defined as Special Screening for neurological eye and ear disease -- glaucoma.)
Comprehensive Examination (-92014)
Refraction (-92015) $ 15.00
2 office visits for extended diagnostic testing (-99213)
Gonioscopy (-92020) $ 41.14
Threshold Visual Field (-92083)
Fundus Photography (-92250) $ 66.24
Nerve Fiber Analysis (-92135-99-26-RT)
Nerve Fiber Analysis (-92135-99-26-LT)
ALT (-66821-55) $ 44.60
AquaFlow (-66170-99-55-RT) ($215.39 x .667)
New code, new questions
Many questions arise with a new code and available services, including the following:
- Can I perform other tests, if indicated? Answer: No, reschedule the patient for a later date.
- If I discover other problems, can I convert the exam to a 99xxx or 92xxx? Answer: Yes, but it would be better to complete the screening and reschedule for further services or tests.
- May my established patients schedule this screening? Answer: Yes, if your previous exams didn't address the risk for glaucoma.
- When the patient returns for another visit, do I code him as new or established? Answer: Code as an established patient.
The practical considerations for assisting patients at risk for glaucoma with this new screening code are enormous.
It's estimated that nearly
11 million Medicare patients who fall into the risk categories for glaucoma screening haven't visited an eyecare professional. Assuming that approximately 50,000 Medicare eyecare providers exist , an additional 220 patients would be added to each practice if all could be reached and convinced of the need for screening.
The screening code was added to prevent vision loss from glaucoma; you should publicize it to help meet its goal. The American Association of Retired Persons has listed the service on its Web site.
You may market the screening in your office. It's always wise to contact your carrier to find out about any established marketing or public service guidelines.
Glaucoma surgery comanagement
Many optometrists provide post-operative care for cataract and refractive surgical patients. However, you should also consider care after glaucoma surgery.
Trabeculectomy and aqueous shunts are procedures associated with complications and require multiple visits that often preclude postoperative optometric care. But more and more, O.D.s are involved in post-operative care for argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT).
Recent Food and Drug Administration approval of a non-penetrating surgical procedure that lowers IOP to near the levels of invasive surgery with fewer post-operative complications and quicker visual recovery may evolve into commonly co-managed treatment for uncontrolled or non-compliant glaucoma patients. Procedure codes and the Medicare fee schedule for the 90-day post-operative period include:
- trabeculectomy (66170-55) (Fee: $215.39)
- aqueous shunt (66180-55) (Fee: $199.53)
- argon laser trabeculoplasty (66821-55) (Fee: $44.60)
- selective laser trabeculoplasty (66821-55) (Fee: $44.60)
- non-penetrating deep sclerectomy with AquaFlow collagen implant (66170-55) (Fee: $215.39).
While it's unlikely that glaucoma surgical patients would be returned to you on the first postoperative day, transfer of care during the first 30 days is becoming more common with laser and non-penetrating procedures. Remember that co-management requires a clinical basis for delegating postoperative care, patient consent and development of the program that's in the best interest of the patient's care and optimal outcome.
Use International Classification of Disease Codes from the 9th edition (ICD-9) for diagnosis codes when billing for glaucoma. The only code for glaucoma that generally varies from the ICD codes is the V80.1 code that we described earlier.
It's always best to use the most specific code that's available that describes the patient's condition. Whenever possible, avoid 365.9 -- Unspecified Glaucoma; you have more definitive codes to choose from to describe a disease.
Ask your payers for a list of the diagnosis codes they consider appropriate for the procedure codes commonly used. If you find that a diagnosis code you feel is appropriate isn't included on the list, you can request that a code be added. You'll need to provide written justification for this requested change.
The codes that usually drive reimbursement for glaucoma are:
Using the "V" codes
Occasionally a patient will be using an oral medication that can cause IOP to rise and potentially create a secondary glaucoma condition. To provide the appropriate care, you must evaluate the patient's IOP.
If you discover that there's no increase, how should you code the diagnosis portion of the claim? The answer is to use the "V" diagnosis codes. Several codes may be appropriate in this instance:
- V67 -- Use this code for follow-up examinations
- V67.5 -- Use when following other treatment
- V71 -- Use for observation and evaluation for suspected conditions not found
- V71.8 -- For observation for other suspected conditions.
List the "V" diagnosis code as the first or primary diagnosis on the billing form. The second diagnosis is the suspected condition, such as 365.11 -- primary open-angle glaucoma.
Realizing patients' value
Optometrists, as primary eyecare providers, are the optimally trained, geographically distributed and logical professionals to coordinate the care for patients who are at risk for or diagnosed with glaucoma.
Appropriate delivery of care and use of diagnostic tests will provide the data and information that you need to manage these patients and provide the guidance to prevent unnecessary vision loss. If you use proper coding and billing, these patients are also a valuable resource for your practice.
Let's look at two possible years in the life a glaucoma patient using the Medicare national reimbursements (see
"Year of Glaucoma Diagnosis and Treatment
Several years after initiating therapy, the doctor adds topical medications to lower IOP without success. He performs appropriate tests to determine the best treatment options. Early in the year, an ALT is performed on each eye 4 months apart, with the O.D. providing the 90-day postoperative care.
Later in the year, a non-penetrating procedure is performed with AquaFlow collagen implant (right eye). The O.D. provides the final 60 days of postoperative care (see
"Continued Care,"). As you can see, the glaucoma patient is a valuable long-term component in any primary eye care practice.
One of the most difficult aspects of treating glaucoma is keeping the patient compliant with his prescribed treatment. With the new options available to control IOP and new research underway, the outlook for vision preservation is always improving. Still, glaucoma patients are never cured and require a lifetime of care and reminders to take their medication.
You provide a valuable service to these patients and deserve appropriate value for your expertise and guidance. Unfortunately, many O.D.s don't properly code and bill for their services and so don't get the capital they need to invest in new technology.
It's important that you understand the details of the coding and billing system so that you can be valuable to both your patients and your practice. Follow this advice, and you should be on the right path.
Dr. Lahr is the director of Eye Services at the Federal Correction Institute at Sandstone, Minn., the director of Primary Eye Services for STAAR Surgical and a senior consultant for Coding and Billing with Cleinman Performance Partners.
The Ocugene test can tell the future.
BY CHRIS QUINN, O.D., F.A.A.O., Iselin, N.J.
Since the human genome project began, we've been speculating that one day we may be able to run a blood test and diagnose glaucoma or perhaps utilize gene therapy to actually treat it. Now a genetic assay is commercially available to test for the presence of mutations in the trabecular meshwork
response protein (TIGR)/MYOCILIN gene.
Beginning in 1997, a series of mutations in the
TIGR/MYOCILIN gene were identified and associated with juvenile glaucoma. The gene codes for a protein that's formed in the trabecular meshwork (and other parts of the eye). Production of this protein is substantially increased when exposed to glucocorticoids and may result in an obstructive influence of the trabecular meshwork.
A mutation of the gene may lead to lack of proper regulation of the production of the
TIGR/MYOCILIN protein and may play a role in primary open-angle glaucoma. A mutation has been identified in as many as 4% of primary open-angle glaucoma patients. One recent retrospective study has linked the genetic mutations for
TIGR/MYOCILIN with both higher IOPs and more damaged visual fields in patients who have glaucoma.
Insite Vision, an ophthalmic therapeutics, diagnostics and drug-delivery company has released the Ocugene glaucoma genetic test. The test consists of a pair of buccal brushes that are used to obtain a sample of cells from the oral mucosa inside of the cheek. Obtaining the sample is painless and requires no anesthesia. After the patient rinses his mouth with fresh water, you gently brush the inside of his cheek with the brushes to obtain the sample. Firmly sweep and twirl between the upper gum and cheek for 30 seconds (you'll need to obtain a sample from both sides). The technique should collect cells but not draw any blood.
After you obtain the sample, seal it in the plastic container supplied with the kit and forward it to an analytical lab. The lab extracts DNA from the samples and analyzes for the specific genetic mutations. The test results are generally available in 2 weeks.
The kit comes with all the supplies you need to perform the test including instructions, swabs, transport tubes and an overnight shipping envelope with preprinted label. Your cost for the test kit, including the analysis, is $200.00. You need only obtain and label the sample, fill in the consent and test order form and ship the package.
Although the test won't be useful for all glaucoma patients, it may help in diagnostic evaluations of patients at high risk for glaucoma who haven't yet developed glaucomatous optic atrophy or visual field loss.
Dr. Quinn is center director of Omni Eye Services, a regional optometric co-management center with offices in New Jersey. He's president of the New Jersey Society of Optometric Physicians.
Optometric Management, Issue: September 2002