LET’S FACE it: These are the best of times, and these may be the worst of times. The transformation of the healthcare reimbursement system from a fee-for-service (FFS) model to an outcome-based model is going to be a rough ride for physicians. How doctors manage that patient from a clinical basis will be extremely important to the health care plans, accountable care organizations, etc. Why? Simply put, if the objective of outcome-based care is to be measured on the quality of the care provided and not on the quantity of care provided, then the practitioner who can achieve the desired quality measure with the least amount of care provided wins.

Managing a glaucoma patient will be one of the primary areas affected in an outcomes-based world. The metric that doctors have to meet is a fairly simple one – getting and maintaining a 15% reduction in IOP.


In a traditional FFS world, when a patient is identified as a “glaucoma suspect” (I use that term only in an illustrative manner), typical optometrists go into a mindset of doing every clinical diagnostic test they can think of to protect themselves, and, sadly often, to embellish their reimbursement.

In my consulting practice, it is not uncommon for me to see clinical records that show identical glaucoma workups for anyone having a suspicious diagnosis. The sheer number of tests performed is generally not supported by medical necessity in the clinical record, but typically consists of:

  • 92083 – Visual Fields
  • 92250 – Fundus Photography
  • 92133 – OCT of the Optic Nerve
  • 92134 – OCT of the Retina
  • 92132 – OCT of the Anterior Segment
  • 92145 – Corneal Hysteresis
  • 92275 – Electroretinography
  • 95930 – Visually Evoked Potential

If I just took the CMS National Average Maximum Allowable Reimbursement for all of these tests and summed them up, it would total $544.05. This does not include the office visit, which is often also upcoded. This would bring the total of the initial workup to more than $600.

Now, while you may think that is great for your practice, it is not so great for your practice profile, the profile that is created through the normal daily submission of claim data. You see, with the advent of the ICD-10, the ability to calculate the cost per provider per diagnosis has become extremely granular and makes intra-professional comparisons very easy to do. So, if provider A is testing the heck out of all glaucoma patients and is good at achieving a 15% reduction in IOP, and provider B is a more judicious tester and is only doing tests that are medically necessary to do and is equally good at achieving a 15% reduction in IOP, which provider is going to be more attractive to a health plan or ACO? That’s the easy part — the one that costs the system less money and gets equal quality outcomes.


In an outcome-based world, providing efficient and effective clinical care is going to be the mantra to live by. By incorporating this thought process into your clinical care today, you will most likely benefit from being included in provider panels and health plans in the future. OM