By Daniel Epshtein, OD, FAAO
April 17, 2019
Cataract co-management is a prime opportunity to serve patients, to extend your relationships with local ophthalmologists, and to grow your practice.
Profitability with Little Needed Investment
Aside from improving patient care, the best part of cataract co-management is the lack of investment. The same equipment used to provide medical eyecare is used to determine what surgical options are appropriate for the patient, and to manage these patients post-operatively. I try to image all patients with OCT and corneal topography before referring for cataract surgery, that way I can be certain there is no corneal irregularity or macular disease present.
When co-managing a cataract surgery, the post-operative fee is 20 percent of the overall charge. This 20 percent entails a 90-day global fee after the surgery date. Depending on when the optometrist assumes care of the patient, they will bill for a portion of that 20 percent.
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For example, if the optometrist assumes post-operative care on the eighth day after surgery, then the optometrist will bill for 83 of 90 days of the 20 percent fee. According to national average medicare rates, a cataract surgery is $654. Twenty percent of this fee would go toward post-operative care. So, depending on when the OD assumes care of the patient, the fee can be up to $130.
When co-managing a patient, who opts for premium services such as multifocal IOLs or femtosecond laser assisted cataract surgery, the co-management fee is increased. Depending on how the additional costs for the premium services are split between the OD and the surgeon, this fee can vary, adding another $200-$1,000.
Coordinate Payment & Communication with OMD
To ensure timely and full payment, it is important that the OD and OMD are on the same page. It is important to make sure the surgeon is billing for cataract surgery with the appropriate modifiers, and it is equally important that the OD is sending proper consultation documentation to the surgeon.
When billing it is critical to keep track of when care of the patient is assumed by each doctor. When I first started working with cataract patients, I referred to a short piece from the AOA on cataract co-management. It is a quick read with a ton of information on getting started with billing cataract co-management. Surgeons are often more experienced than optometrists in billing for co-management, and can be a great source of information to make sure that you are billing correctly.
To be an ideal co-management OD partner, it is important to provide the surgeon with the following:
1. Refraction and BCVA
2. Pupil size
3. Habitual refractive correction
4. Failure of refractive correction modalities, such as failed multifocal contact lens fit
5. Keratometry, preferably with topography
6. Medical history including meds
7. Ocular history
8. Co-morbidities such as epiretinal membrane, history of herpes simplex keratitis, history of diabetic macular edema
9. Macular OCT imaging, especially important for multi-focal and extended depth of focus IOLs
10. Recommendation for IOL type and/or additional procedure, such as iStent
Post-operatively, it is essential to provide timely documentation that you have assumed care of the patient. I send results of each post-op visit to the surgeon, so we are both aware of how the patient is progressing.
Learn How to Educate Patients
Managing post-surgical expectations of cataract patients is an important part of the process. I counsel my patients in length on the process of cataract surgery, from their evaluation with the surgeon to their last post-operative day. I describe that neuro-adaptation may take several months, during which time they may have issues adapting to their new “eyes.”
If they have co-morbid disease, such as geographic atrophy, I discuss how the two conditions (cataract and geographic atrophy) affect vision. When I recommend premium services, such as an extended-depth-of-focus IOL, I ensure that their expectations are appropriate. I often describe a theoretical spectrum of refractive correction necessity.
At one end of the spectrum are patients who need full-time refractive correction and at the other end are patients who never need refractive correction. I then describe the different options available for the patient, but note that, unfortunately, with our current technology, there is no way to make a patient completely independent of a refractive correction. However, many patients with multi-focal, or extended-depth-of-focus IOLs can be 95 percent independent of refractive correction, requiring only reading glasses for some near tasks.
I also emphasize the importance of the post-operative period and compliance with medications and follow-ups. I say that even a perfect surgery can be ruined if patients do not strictly comply with post-operative directions.
I am a big fan of MIGS procedures for my glaucoma cataract patients. These procedures have a great safety profile and often make it easier for me to control the patient’s glaucoma in the long-term. I have a few images and videos that I show patients on the computer in the exam room, so they can better understand the procedure.
Keep Patients in Your Practice
At the end of my discussion with the patient, I discuss the logistics of the surgery. I explain the post-operative period and the option of completing post-operative care with me or with the surgeon. I finish this discussion by explaining that whether the surgeon or I do the post-operative care, I will continue seeing them for comprehensive care after the global period.
Build Relationships with Local Surgeons
Before starting a co-management relationship with a surgeon, I learn about the surgeon’s practice philosophy. I like to observe the surgeon during a post-operative day and discuss hypothetical patients, so we are on the same page going forward. It’s also a great idea to observe the surgeon in the operating room if you can. Every surgeon is different, and it is important to understand individual nuances to better serve our patients and strengthen the co-management relationship.
I refer to three cataract surgeons and one separate clinic for cataract surgeries. I have co-management relationships with two of these surgeons, but refer to the others for patient insurance reasons or for specific combined surgeries. As with many opportunities in eyecare, I developed these relationships by meeting the surgeons at local continuing education events and through other optometrists in the area.
Reach Out to Prospective Patients
Community engagement at senior centers can be a great new referral source. I have spoken twice at senior centers, discussing cataracts and comprehensive eyecare. The interaction was casual and because of this, everyone was engaged in the conversation, asking many questions. About 30 percent of the people I spoke to already had cataract surgery, but many did not get yearly comprehensive exams, which was a great opportunity for me to provide education on the importance of periodic eyecare even in patients who see well and already had cataract surgery.
Cataract co-management is a great way to serve our patients. It can make a scary period in their lives a little calmer and strengthens relationships between ophthalmologists and optometrists. The integrated model of eyecare will likely become more common in the future, as ophthalmologists are called on to perform more surgeries, leaving optometrists to provide non-surgical eyecare in all its forms. Many optometrists already participate in this model of care, and hopefully many more will begin to provide care in this already-established model of eyecare.
Daniel Epshtein, OD, FAAO, practices at Mount Sinai St. Luke’s Hospital and at an independent practice in New York. Previously he worked at a high-volume, multi-specialty practice where he provided refractive, medical and perioperative care. He combines his research experience with the latest clinical practices to provide the best possible care for his patients. To contact him: email@example.com