Article

Co-Management: A How-To Guide

Provide the best collaborative care, while also following CMS rules

I was on a roll. I had already determined that this 64-year-old patient, who presented at my practice for consultation ahead of his cataract surgery, was the perfect candidate for a multifocal IOL. I had succinctly explained the particular benefits, as well as the risks, of what this IOL would enable him to see without glasses. As I was almost through my discussion with him about how he would likely still need prescription glasses for reading small print, he interrupted me:

“Dr. Retina, who sent me here, told me that I should get the regular implant because I could never wear those no-line bifocals. He has been my doctor for years, and I really trust what he says!”

With my ego deflated by the apparent disagreement between the referring O.D. and myself, I begrudgingly went to see the next cataract patient in the adjacent room. This patient was the perfect candidate for a toric presbyopic- correcting IOL, and I, again, went through my standard discussion of the pros and cons of the IOL before scheduling her for the surgery.

As I drove home that night, I was struck by the stark contrast between these two patient encounters. Both had similar conditions and expressed similar needs of spending multiple hours on a computer each day with no close-work hobbies, as identified by the practice’s lifestyle questionnaire, but different ideas of how to best fulfill those visual needs. The only real difference in these cases and the chosen management path was communication — that is, the communication among the referring optometrist, the patient and the surgical clinic, which impacted these patients’ choices. And that is the true essence of co-management, the communication from all to the patient.

Co-management has been defined many different ways, but in its truest sense, co-management is best described as the shared, collaborative care of a mutual patient between two doctors. (See cms.gov for co-management information.) This sharing of care must be agreed upon by all three parties involved; the patient, the referring doctor and the surgeon. (See, “Safe Harbor Regulations that govern doctors at https://bit.ly/2oWqA04 .) And essential to this relationship is communication between the two providers.

While beginning with communication, the next step in the co-management process is making the actual referral. You, as the referring doctor, should decide which surgery center your patient is referred for their procedure. But much more than simply scheduling the appointment, your office staff should also send a history of the patient’s exams, along with a referral letter delineating what your discussion has been with your patient and what type of surgery you recommend. This is a great place to note any unique challenges for the patient or reasons that you feel a certain IOL would benefit this patient over another IOL. This will increase the likelihood that your patient will receive the procedure that you both desire, but it also gives the patient confidence that your transfer of care is contiguous.

Here are some steps to get the co-management working smoothly.

1. CHOOSE THE SURGEON

This should take a lot of thought. You, obviously, want to partner with a physician who has impeccable surgical skills. This means the surgeon has embraced premium IOLs, as well as “standard” IOLs, and stays current on the latest surgical techniques and advancements.

Your patients deserve and, oftentimes, demand, high-quality, cutting-edge surgical technology. I recommend you develop a solid co-management relationship with no more than two surgeons within the same group. The expectations of the patient, optometrist and ophthalmologist will be easily met.

Equally as important as the surgical skill of the ophthalmologist is the treatment philosophy of your co-manager. Ideally, you and the surgeon should be on the same page as to how the post-operative care will be delivered, what type of post-operative medications will be used and, in general, just how patients should be cared for.

For example, in the case of post-operative medications, some surgeons prefer to use three different medications, some embrace generics, others use one bottle of a compounded “triple agent” and yet others prefer dropless surgery.

You, the referring doctor and staff should play a leading role in this discussion. If you’d like the opportunity to taper steroids more quickly or if you feel compliance is better when patients don’t have to use drops as often, then this should be communicated to the surgeon. Though there are exceptions to all things, once you and the surgeon have agreed on a post-operative drop regimen, consistency improves, miscommunication fades away, and the outcome for your patient will be enhanced. More-over, this instills in the patient confidence that this management is what is best for them.

It is also critical to develop a relationship with a few of the surgeon’s key staff members who understand what you are expecting for the patients you refer. The more people who are knowledgeable about what the O.D. and patient expect decreases the likelihood of miscommunication. Additionally, it’s a good practice that each doctor have the other’s cell phone number to maintain communication.

Lastly, the schedule of post-op visits should be decided and agreed on before any referrals take place. Some O.D.s prefer to see their patient on day one post-operatively, whereas others are more comfortable seeing the patient after the first week. Whichever your preference, it needs to be shared with the surgeon. Once agreed on, instructions should be printed, and the drop regimen should be discussed at both the surgical center at the time of discharge and at every post-operative examination with the co-managing optometrist.

2. EMPLOY THE CORRECT FEE STRUCTURE

Once you have found the right surgeon with whom to partner and have set up the principles of the co-management relationship, it is important that the correct fee structure is understood by all involved (including the patient). The basic premise is simple: The surgeon bills for the surgery, and the optometrist bills for the post-operative care.

For a standard cataract surgery with a monofocal IOL implanted, the surgeon’s office uses code 66984-54 RT (or LT, depending on which eye was done). A diagnosis code is used (H25.12 for example), and that office sends the claim to the proper insurance company with a date as to when the care has been relinquished. THIS CLAIM IS FOR THE SURGICAL PORTION ONLY!

When the patient returns to the co-managing O.D.’s office for continued care, whether at day one or day seven, the optometrist will generate a separate claim for the post-operative care. It is important to use the same diagnosis code as the surgeon used or the claim will be rejected. (This highlights the need for a flow of communication between offices.) The procedure code is the same, except that you will be using the -55 modifier, which indicates post-operative care, rather than -54. RT or LT modifier must also be used. (66984-55RT would be the proper code in this scenario.)

This simple scenario has a few caveats that must be adhered to, though. First, in the surgical chart the surgeon must indicate at what date the care is being relinquished and to whom the care is being transferred. Similarly, on the optometrist’s claim, the doctor must indicate who the surgeon was and what date the post-operative care responsibility switched to this particular optometrist. This is typically done the first day after the procedure. Also remember, that the post-op management period is for 90 days. Thus, only one claim has to be sent for the entire 90-day post-op course. The exception to this would be an incident in which the patient has an eye-related problem, aside from the surgery. A new diagnosis code should ensure a new billing code. The new billed procedure needs a -24 modifier, which indicates it is a separate diagnosis during the 90-day global period (for example, 99213-24).

This process is tried and true and acceptable by all insurance companies for standard cataract procedures using standard IOLs. When a newer technology or technique has been performed, such as when a premium IOL has been used or femtosecond laser-assisted surgery has been performed, there is an increased fee that most insurance companies will not cover. This expense must be borne by the patient and will need to be accounted for and collected. This process, in my experience, tends to be overcomplicated and underexplained. It should be a very straightforward explanation that takes place in both the O.D. and M.D. offices before the surgery is performed, and the monetary requirements should be denoted on a document and signed by all three parties.

It is imperative that if any additional expenses are going to occur, the patient signs a waiver of benefits at both offices, indicating understanding that not all of the services will be covered by insurance. Remember that even when there is a premium fee, the 66984 codes are still generated and sent to the proper insurance company for payment of the “traditional” surgery portion. The remaining expense for the non-covered services will be paid directly to the surgeon and optometrist by the patient. By using proper documentation and having conversations about these charges in both the surgeon’s and co-managing doctor’s offices, miscommunication will be avoided, and the surgical experience will be further enhanced.

WHY CO-MANAGE?

Co-management of cataract surgery allows your patients’ access to the best surgeons and the best surgical outcomes, while still maintaining the comfort they feel with their primary care eye doctors.

In my 30 years of co-managing patients, I have found that those patients whose post-operative care is delivered by their optometrists tend to have better surgical experiences, show better compliance with their post-op medication regimen and remain strongly loyal to their referring optometrists.

Both the surgeon and optometrist gain from the experience as well, by caring for patients at the highest levels of their respective training. The bottom line, however, is best said by Dr. William Mayo, a founder of the Mayo Clinic: “The best interest of our patients should be our only interest.” That is why we co-manage. OM