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I'm beginning to think that corneal topography does not get enough respect.
There are still many eye care practitioners who don't own a topographer and many
who have one but don't utilize it on a regular basis.
I'm not quite sure why interest in corneal topography is lower than other
instruments, such as retinal cameras or nerve fiber analyzers, but I have some
suspicions and I think many practitioners are missing the boat. While
topographical imaging is not a necessity for prescribing a contact lens or for
monitoring ongoing contact lens wear, I find the data provides many clinical
advantages. Contact lens care is a large, important part of our practices and
I'm interested in providing the highest level of service, not a basic level.
Furthermore, contrary to popular opinion, a corneal topographer can generate
significant revenue for a practice. While that may not be the primary reason for
using the device, I'm not ashamed of earning higher fees by providing a higher
level of care. I think the misunderstanding about generating revenue from
topography stems from the realization that it may not always be billable to
medical insurance plans. It's true that insurance coverage varies widely for
corneal topography and one would need a supported corneal diagnosis if the
procedure were covered at all, but it's a mistake to assume that billing and
coding is the only way to earn fees in eye care. Contact lens care is typically
a non-covered service on medical plans and it is often covered by an allowance
on vision plans. That makes it a private pay service, which is still the best
The clinical advantages
Corneal topography is the premier technique to monitor corneal shape and
integrity. We were all taught to use a keratometer for this purpose, but that is
like comparing an automobile to a skate board. I capture and review corneal maps
for all contact lens patients at every annual eye exam. I'll admit that analysis
of the topographical images is usually very quick, but that's the beauty of it.
I can see at a glance what is going on and I can assimilate a great deal of
information. Granted, the corneas of most contact lens wearers are within normal
limits, but that does not reduce the value of the test. Most fundus photos are
normal also, but we still gain a huge amount of information from them.
Nothing has helped me explain astigmatism, localized corneal edema, or other
corneal abnormalities better then showing a person a 3D image (not just the
color map) of his own cornea. Reviewing the corneal maps in front of the patient
sets your contact lens services apart from the average practice. Patients
realize they are getting the best care possible because they see you use the
latest technology for contact lens fitting and management. I often say something
like, "We take these computerized images of your cornea every year so I can
monitor the shape and curvature of the front of your eye where the lens sits.
This data helps me check the fit of your contacts while monitoring the health of
your corneas." I may go on to comment on some unique factor or just conclude
that all is normal and looks good.
The financial aspects
I rarely charge a separate fee for corneal topography in my practice and it
is even rarer for me to try to bill an insurance plan for it. I simply include
the procedure as part of my initial contact lens fitting service and it is also
included in the ongoing contact lens evaluations that are performed yearly along
with a comprehensive eye exam. I charge a separate fee for contact lens fittings
and for contact lens evaluations; they are itemized in addition to the eye exam
fee. Contact lens fitting fees and evaluation fees cover additional tests that
are only performed on contact lens wearers. Corneal topography is one of those
tests. I can't tell you how much to charge for contact lens evaluations or
fittings, but I think most practitioners don't charge enough. It's elementary to
conclude that doctors who include topography as part of their services would be
justified in charging a higher fee than those who don't.
Features to look for in a topographer
Easy for technicians to operate. I don't want a special instrument
that is so tricky to use that only the doctor can do it. This leads me to
prefer table-mounted instruments that have a chin rest and head rest for the
patient and operate with a joystick and a video monitor for alignment. It
should be easy to line up and snap an image.
Easy to network. I want to display the corneal maps on a flat screen
monitor on the desk in each exam room so the doctor can review the images in
front of the patient. This same computer and monitor would also be used to
view retinal photos. Some topographers are difficult to network or require
multiple licensing fees. Multiple-use instruments, like autorefractors that
have a simple topographer incorporated may not be network ready.
A topographer that has a separate computer; not integrated. I like to
see the measuring part of an automated instrument plug into any generic PC
or laptop and have the software provided separately. This allows you to not
overpay for a built-in computer that is too slow from the beginning and it
allows you to service or replace the computer when that part of the system
fails. All computers fail eventually, often sooner than we like.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.