NC Medical Board reverses summer decision on CPT codes for ODs

Ophthalmologists have convinced the board to reverse its opinion to allow optometrists to perform injections.

RALEIGH, N.C. — On June 21 the North Carolina Medical Board (NCMB), at the request of organized optometry, issued an opinion allowing optometrists to perform five CPT codes, specifically subconjunctival injections, fluorescein angioscopy and angiography, indocyanine-green angiography and intralesional injections. However, on Sept. 23, the board unanimously reversed its opinion.

The story of North Carolina and its optometrists goes back much further than June 21. Because of a 1993 lawsuit between optometry and the medical practices of ophthalmology, pediatrics, neurology and dermatology, the simple issuance of the opinion of the medical board was not enough to give optometrists the ability to perform injections.

Optometry vs. organized medicine

In 1993, organized optometry stated that it would allow itself the privilege to perform 130 medical codes. This announcement set off a wave of protest that eventually brought forth the lawsuit of organized medicine vs. organized optometry, which landed in the court of Judge Henry Barnett.

During the legal wrangling of the lawsuit, the NCMB issued an opinion stating that approximately 50 of those 130 medical codes could be used only by MDs. Judge Barnett decided to rely on the opinion of the medical board. According to a member of the North Carolina State Board of Optometry Examiners (NCBOE), the decision was appealed, but before the appeal was heard, optometry and medicine agreed that they would consult before optometry expanded its scope of practice. The board member, who asked to remain anonymous, said they would agree if they could — if not, optometry would pursue whatever course it felt necessary.

According to the Consent Agreement of 1994, organized optometry — when it believed the education and training of its optometrists was proper — would come before the medical board and request the issuance of certain codes. However, to be able to perform those codes, they would also need to gain the approval, through a review process, of all the other medical societies listed in the original lawsuit. If the other parties and the medical board agreed, optometry would be allowed the use of the codes it requested.

In 1997, the Consent Agreement was used, and properly trained optometrists were granted the codes to perform punctal occlusion and foreign body extraction.

In 1999, optometry again made a request of the medical board to perform certain other procedures; however, they were refused. At that time, the board stated that there had not been enough basic education on the part of organized optometry to grant any more codes.

After further hearings, the medical board approved the codes June 21, 2000.

A “dangerous path”

“The board took a path that was dangerous to patients,” said Michael Brennan, MD, when it issued the opinion allowing ODs to perform those five CPT codes.

Dr. Brennan, an ophthalmologist who practices in North Carolina, explained that, unlike oral and topical prescriptions, which optometrists in North Carolina are authorized to issue, these procedures bordered on surgery and were medical concerns that only a trained and licensed medical doctor or — under a doctor’s orders — a nurse should be allowed to perform. “It’s a matter of patient safety. This was a hasty and dangerous opinion that was published [by the medical board]. It sent the wrong message,” Dr. Brennan said.

Chief among Dr. Brennan’s and the North Carolina Society of Eye Physicians and Surgeons’ concerns was that this kind of opinion on the part of the medical board could be used as an example in other states and in future litigation to allow optometrists greater — and possibly dangerous — medical allowances.

Thomas E. Eichhorst, JD, director of the state government relations center for the American Optometric Association, said that North Carolina is not the first state to seek such privileges; therefore, this is not a radical departure from the scope of practice that many optometrists across the country are already exercising.

“Twenty-one other states and the District of Columbia authorize ODs to use injectables at least for anaphylactic purposes,” Mr. Eichhorst said. “That’s a sizable number of states, and the number is steadily increasing. I think that helps put the North Carolina situation in perspective; [the wish for ODs in that state to have injection privileges] is not an isolated occurrence. North Carolina is just very unusual in that the medical board has involved itself in this process.”

Dr. Brennan said it was also a concern that if ophthalmologists allowed this opinion to go unchecked, other fields of medicine might unwittingly sign off on the Consent Agreement of 1994 that would ultimately allow optometrists in North Carolina the use of these injection codes related to their patients’ conditions – for example, intralesional injections in dermatology patients.

“To allow optometrists to do injections is unsafe,” Dr. Brennan said. “It is a potentially dangerous procedure. I did an injection earlier this week near a child’s eye, where any number of things could potentially go wrong and would need immediate medical attention.”

NCMB opinion reversed

While the medical board reversed its opinion on Sept. 23, it also passed a motion that might eventually grant the codes. The motion stated that a collaborative practice committee should be established between the NCMB and the NCBOE based on the Clinical Pharmacist Practitioner model to develop methodology address implementation of the five CPT codes.

According to Cynthia A. Hampton, MD, president of the North Carolina Society of Eye Physicians and Surgeons, the motion attempts to develop a Collaborative Agreement and is similar to a recent collaborative “clinical pharmacist practitioner” category in which the medical board is involved.

Dr. Brennan stated that he and other medical practitioners consider injections an invasive procedure, one that necessitates the proper medical training, not just on how to do the procedure, but also how it affects the body as a whole.

“While some oral and topical pharmaceuticals may be in the scope of practice for optometrists, physicians are beginning to realize there is a large gray area involving surgery and many injections where MDs must hold the line,” Dr. Brennan said. He mentioned that even procedures done under the “direct supervision of an ophthalmologist” might not be the answer to the problem.

Just a bump in the road

For optometrists, the real question is not whether or not they should be allowed to do injections, but whether or not injections are considered surgery. They are asking the state medical board to define what injections are and under whose scope of practice they fall.

According to the NCBOE board member, “This is just a bump in the road. The medical board will [eventually] approve [the injection codes].” The board member explained that North Carolina is still basically a rural region and that many of the state’s population cannot reach the more urban areas where ophthalmologists can be found.

“North Carolina optometrists are astute and capable practitioners. However, the NCBOE will determine what prerequisites must be met by each OD before using any of the codes in question,” the board member said.

For Your Information:

• Michael Brennan, MD, can be reached at 1214 Vaughn Rd., Burlington, NC 27217; (336) 228-0254; fax: (336) 226-2974; e-mail: brennan@netpath.net.
• Thomas E. Eichhorst, JD, is the director of the state government relations center for the American Optometric Association. He may be reached at 243 N. Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100, ext. 234; fax: (314) 991-4101.
• Cynthia A. Hampton, MD, can be reached at PO Box 27167, Raleigh, NC 27611; (919) 833-3836; fax: (919) 833-2023; e-mail:whampton@gloryroad.net.
• The North Carolina Medical Board can be reached at PO Box 20007 Raleigh, NC 27619; (919) 326-1100; fax: (919) 326-1130; Web site: www.docboard.org/nc/.
• The North Carolina State Board of Optometry Examiners can be reached at 109 North Graham St., Wallace, NC 28466; (910) 285-3160; fax: (910) 285-4546; Web site: www.ncoptometry.org.