Digital Photography: Worth More Than a Thousand Words

This "tool of tomorrow" will help you achieve clinical efficiency that your patients will appreciate today.

digital practice
Digital Photography: Worth More Than a Thousand Words
This "tool of tomorrow" will help you achieve clinical efficiency that your patients will appreciate today.

In these economic times, we're all looking for an edge -- a way to increase patient satisfaction, clinical efficiency, quality of care and ultimately, the bottom line. Capital equipment investments, or more specifically, the purchase of a digital fundus camera, may provide your edge.

Why do I need a one?

You might ask, "Why would I need a digital camera, especially with the recent economic downturn?" Keep an open mind and consider these facts:

► In tough economic times, buyers hesitate to invest in new technology. By making investments, you differentiate your practice from those of your peers and competitors. And fortunately, the eyecare world has experienced a tremendous leap in technology in recent years.

► The patients of today are submerged in technology. One in three people own a personal digital assistant and one in two have a cell phone. These patients expect their healthcare providers to be technologically advanced as well. (In optometry, we're just starting to catch up and move past a manual phoropter, a DOS-based visual field and a mechanical tonometer.)

► Digital photography can help to advance your practice, increase your profits and become more clinically efficient today.

► Look at the primary reason why people don't get an annual eye exam-dilation. They hate it. With some digital nonmydriatic cameras, you can obtain an excellent view of the posterior pole and peripheral retina without dilation. And it pays off. In my clinical experience, one out of three patients pay me to use the nonmydriatic panoramic camera so that they can avoid dilation.

► Digital imaging allows instant accessibility to the high-quality images that are easy to use for both patient education and management decisions. Using digital images as a teaching aid augments a patient's understanding of his problem and may enhance compliance. Additionally, now your clinical information isn't on a sheet of paper, but is digital, allowing you to store, retrieve, copy, e-mail or send images that are equal to or better than film and without any effort.

From a marketing perspective, word will travel quickly that your office has technology that allows for you not to dilate, which in turn allows access to a subgroup of patients who would normally never come to you. Those of you who are waiting for the prices to go down are losing revenue as well as your competitive advantage. Remember that cutting-edge technology is rarely inexpensive.

How do I choose a camera?

In the case of any capital purchase, we always weigh which is the best piece of equipment and what we can actually afford to buy, finance or lease. To help get started, ask yourself the following questions:

  • What are my needs?
  • How will this piece of equipment meet these needs?
  • How will it increase my efficiency?
  • Which is the best piece of equipment to meet my needs?
  • How will this piece of equipment pay for itself or be profitable?

Like many of you, companies ask me to "trial" all of the newest, latest and greatest equipment available. Every time I ask myself, "Do I really need this?" Hopefully you've read the first section of this article and have a clear sense as to the answer to that question. Now do your homework! Analyze the strengths and weaknesses of each piece of equipment before you ever contact various vendors. The sidebar,"Review Your Choices," on page 46, lists some of the digital fundus cameras currently available as well as some of their features. Be sure to contact the manufacturers for additional information.

If you currently use film photography, then ask your photographer what technology may help enhance her job. She may be able to provide you with valuable information on her needs as well as her knowledge level on various cameras and software packages available. Most likely she already has a wish list and has done most of the homework for you.

For those of you who don't currently use photography, consider these issues when purchasing a camera:

► Can you integrate the camera system with various software packages or does it use proprietary software? What are the file sharing and exporting options?

The concern is that other electronic medical records (EMR) systems may not be able to "talk" to the proprietary software, which may lead to problems as software platforms change over time. An open architecture will allow you to have the freedom of choice to purchase the equipment you feel best suits your patients' and practice's needs over time.

► How wide is the field of view? Can you use the technology on undilated patients and still receive excellent an excellent field of view that's comparable to binocular indirect? (In my opinion, some nonmydriatics may not provide a sufficient field of view to serve as an alternative for binocular indirect). If I buy a mydriatic camera, does my practice see enough pathology to justify the investment?

► Is the system upgradeable and who pays for the upgrade? This is especially important if you're contemplating converting your existing film camera to a digital camera.

► How do you store data? Are the images compressed? Ideally, you want to store images in uncompressed .jpg or .tiff files. Compression may potentially result in a loss of image quality. Upgradeable storage is important, especially when you consider that CDs replaced floppy discs and DVDs are replacing CDs and something that hasn't even been developed yet will eventually replace DVDs.

► Is the system encrypted? Does it meet the standards of the Health Insurance Portability and Accountability Act of 1996?

► Does the software allow for modification and manipulation of the image? Is there a search function that allows a search by a patient's name, date or diagnosis? Both of these are crucial to the usability of the device.

► Can you and your staff easily navigate through the software? If not, it's likely that you'll never get the staff on board and you'll get stuck with a large paperweight.

► Does the camera come with a long-term support and service contract?

► Will the system fit in your office? Where is the best place to set it up for both capture and viewing? Is your office capable of being networked?

► Will the digital camera station work as your server for your local area network (LAN)? This will be a good option if you have a smaller practice where image space isn't an issue. In a larger office, or a practice that has multiple offices, you may need a separate server because of networking and storage issues.

► Can you get an in-office test drive before you purchase so you can assess whether the actual device will meet your needs for the average patient?


Do the Math


Revenue: Let's say on average you perform 21 exams each day and only one in three patients chooses to forego dilation. Take those seven patients and multiply them by five days each week and 50 weeks each year. Calculate revenue created at $30 each use (the arbitrary value of the service):

7 patients x 5 days x 50 weeks = 1,750 uses each year at $30 each use = $52,500 each year

Now factor in that each patient stays with you for an average of seven years. Are you starting to see where the value adds up?

Cost: Determine the total operating costs by calculating the initial investment of $40,000 (a mid-range model) plus direct operating costs such as printer/storage costs ($0.10 each use) and warranty costs ($500 each year).

$40,000 + (1,750 uses x 0.10) + $500 = $40,675

Break Even Point: Divide the costs by the number of exams to meet that number. $40,675/$30 = 1,356 uses to break even over a five-year period (expected life span of the unit). That's only 193 clinic days or, in better terms, you should have it paid off by September of the first year.

Gross Profits:

(1st year) = $52,500-$40,675 = $11,825

(2nd year) = $52,5000-$675 = $51,825

(3rd year) = $52,500-$675 = $51,825

How do I pay for it?

You basically have two options when charging for digital fundus photography:

1. Incorporate the cost into your normal and regular examination fees

2. Charge extra for it.

I encourage the latter option because then patients perceive it as an added benefit, which may be the one fact that keeps them coming back.

Most patients leave because of a change in their insurance programs, a change in programs that you accept, a change in their perception of you and your care or because they relocate. Now we can see that the dependence on technology adds one more benefit to returning income to your practice.

In the case of a nonmydriatic camera, even nonpathology patients can generate revenue if you charge for this feature. In most settings you'll see at least one person each day who has ocular pathology. These patients really get you ahead of the game because you can bill their images for a bilateral procedure at a normative cost of $80. For a few friendly billing/coding reminders you may also want to review "Reimbursement Reminders" on page 48.

Now what do you do with it?

Your first priority is to educate your staff regarding the benefits of this new technology as well as how it will positively influence them. You may even want to provide an incentive to your staff for meeting target goals for the number of patients who choose to forgo dilation. Have your staff let patients know that you recommend this option. A few seconds of education by you and your staff helps to increase the bottom line as well as provide better care.

You'll also want to market this new technology to your patients and use it to generate referrals. Offer to send an e-mail copy of the digital image to your patients. Let your patients help you market this technology to their friends, family and co-workers (who are usually on the same vision plan). Send a letter to your patient's primary care provider and include a copy of the patient's fundus photo. Many of them have never truly seen a retina and they are fascinated by it. Use it for comanagement and send a digital image to your retinal specialist or local ophthalmologist. This is especially effective when they don't have a digital fundus camera. You can even do a consult with the patient in the room.

And, for the conservatives out there, if you find pathology you may still decide to dilate to obtain a 3-D view. Then perform and charge for extended ophthalmoscopy (92225) as well as the fundus photo (92250). In most instances the patient will be accepting once you've shown him what you're looking for and why you need to dilate.

Another important point to address is printing. Even if you have the highest resolution camera and the best chip, the quality of the photo will only be as good as the printer's ability to reproduce a high-quality, photographic-like images. If you're using your printout for interpretation notes and general diagnosis only, then a normal ink jet printer will probably work fine. But remember, if you buy a higher-quality printer and use high-quality paper, you're going to add to your costs. Try to find a happy medium for your needs.

Enjoy the benefits of digital

Don't presume to know which patients will elect to pay for digital photography to avoid dilation. A patient's willingness to pay has nothing to do with his income level.

Incorporate a digital fundus camera into your practice and you'll increase your patient base and your bottom line while increasing patient satisfaction and clinical efficiency.

Dr. Morris is a member of the Spivack Vision Centers refractive surgery team and the American Optometric Association. He's also a fellow of the American Academy of Optometry.

David Dremel is clinical services manager at Spivack Vision Center. He is a certified ophthalmic technician and has his Associate's degree in Applied Science.

Mark McElroy is a certified ophthalmic technician.


Reimbursement Reminders

Follow these guidelines when billing for digital photography.

Image Ethically. Code and bill third-party payers for fundus photography only when medically necessary (e.g., when establishing a baseline, documenting a new potentially pathological finding or the progression of a pre-existing lesion). Annual documentation will likely raise a red flag and will most likely ultimately result in an audit. Indications for fundus photography include vitreous hemorrhage; retinal or choroidal lesions, including detachments and intraocular tumors; diabetic retinopathy (baseline, progression and post-treatment of both NPDR and PDR); age-related macular degeneration; retinal drusen; papilledema; and anterior optic neuropathy. Experts recommend using stereo photography to monitor glaucoma patients' optic nerves.

Document Everything. When performing fundus photography, document the type of image or photo you take, the date of service, the reason why you ordered the test and specific defects in the clinical record. Keep these in a separately identifiable area from the normal exam sheet and don't include it in the area set aside for extended ophthalmoscopy. Initial the photo and write any comments or your interpretation directly on the image if you print it out. Always sign and date the record to indicate that you reviewed it.

Code Correctly. The code for fundus photography is 92250 and third-party payers consider the procedure binocular; thus you can only bill it once each visit even though you may take a picture of both eyes. If you only need to take a picture of one eye then use the correct modifier (-52), which is a reduced services modifier code that will reduce the 92250 reimbursement by 50%. If you're concerned that the insurer won't reimburse you for the service for pathology condition then have the patient sign an advanced beneficiary notice before you perform the service. This way the patient knows that he will have to pay for the service if his insurance doesn't cover it.