BLOG: Glaucoma care demands shift to medical-model optometry, medical billing
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As our population size increases and grows older, treatment of ocular disease will become more prominent in optometric practices. Consequently, the percentage of revenue generated by medical management will grow.
For glaucoma patients, specifically, this is a result of the higher level of diagnostic testing and visit frequency required. To maximize profitability and properly care for these patients, it is vital to ensure accurate billing and consistent scheduling of follow-up appointments.
From an insurance standpoint, the chief complaint dictates how the examination is billed. When a patient comes in for a comprehensive or “routine” annual exam to update their glasses and/or contact lens prescription, the visit is billed to vision insurance if they have it. During the exam, which includes dilation, we may discover ocular conditions that require medical management.
Let’s say I diagnose the patient with glaucoma that day based on the appearance of their optic nerves and elevated IOP. We have an experienced biller who is comfortable managing the coordination of benefits. The fundus imaging is billed to the medical insurance, and the rest of the exam — as intended based on chief complaint — is billed to vision insurance.
Regardless of how that encounter was billed, I’m going to bring that patient back for several more visits over the next year or so, which will include:
- a full glaucoma workup including OCT of the nerve fiber layer, visual field exam, gonioscopy and pachymetry within 1 month of the patient’s comprehensive exam;
- an IOP check 3 to 6 months later, depending on severity of glaucoma; and
- an “annual” exam, which may include updates to vision correction, if needed.
Because we have a large practice and patients sometimes see different doctors, we try to keep a well-regimented flow of glaucoma-related testing so that no matter who sees the patient, they know where that patient is within our protocol. This makes it easier for the patient to understand their treatment care plan throughout the year as well.
We explain to our newly diagnosed glaucoma-suspect patients, who were simply expecting an update to their vision correction, that vision benefits will be utilized for this first visit, but going forward, we will utilize their medical insurance benefits for the medical management of glaucoma as necessary. At every visit thereafter, imaging and exams are billed under medical insurance.
Once a patient has a glaucoma diagnosis, they are always a medical patient, because our primary reason for their exams going forward is to monitor a sight-threatening disease — glaucoma. Prescribing glasses or contact lenses becomes secondary.
If you are managing several glaucoma patients, it’s also important to identify good cataract and glaucoma surgical partners to whom you can refer patients for minimally invasive glaucoma surgery, traditional glaucoma surgery or laser trabeculoplasty. Some glaucoma patients will benefit from early surgical or laser intervention in addition to or instead of medical therapy. Afterward, they will still follow-up with their primary optometrist for billable postoperative and ongoing management of their glaucoma.
I recommend visiting and introducing yourself to potential referral partners, as well as their office managers. These relationships are crucial. I know that I personally refer more patients to surgeons in my area whose cell phone numbers I have — not because it’s a popularity contest, but because I feel more comfortable that I can reach out to the surgeon directly when I’m stumped by a complex case or I have a patient who needs an emergency appointment.
I pay attention to how the staff and doctor treat me and what their interactions with patients are like. I monitor outcomes and ask patients to tell me about their positive or negative experiences. Referrals should work in both directions: A good surgical referral partner should send a consultation letter to you after treating your patient, refer patients to you for services that he or she doesn’t offer and contact you personally when there is a decision that runs counter to your recommendation or when there is an unexpected complication.
For more information:
Nicole Albright, OD, is clinic director at Moses Eyecare Center in Merrillville, Indiana, where she also serves as externship coordinator for optometry students at Indiana University and Chicago College of Optometry. She practices full-scope optometry, with a focus on specialty lenses, perioperative care and ocular disease management.
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