Benefits of Co-Management
Benefits to the Patient
- Working with the doctor they know and trust
- Continuity of care
- Peace of mind that comes with knowing that the surgeon has been vetted by their optometrist
Benefits to the Society
- Comparative advantage of utilizing specialists for their designated tasks
- Increased efficiency in delivery of care
- Improved continuity of healthcare delivery
- Reduced costs
Benefits to the Optometrist
- Modern management of refractive errors includes surgical treatments
- Increased awareness of refractive procedures in the general population results in heightened patient expectation that their doctor will guide them through the maze of available procedures
- Availability of treatment options not limited to just contacts or glasses result in increased practice credibility and strengthens the physician-patient relationship
- Co-management of premium cataract services ensures that patients always get the best treatment available at the time of diagnosis
- Improved goodwill, resulting from the patients knowing that the optometrist has his or her best interest as the guiding principle in their care
- Establishment and solidification of a life long relationship with the patient, not limited to just purchase of glasses or contacts
- Prestige that comes with offering most advanced treatment options
- Increased revenue to the practice
Benefits to the Ophthalmologist
- Increased satisfaction of working with patients who have been pre-screened for procedures
- Improved outcomes resulting from better patient preparation and pre-op measurements
- Decreased patient anxiety, as the patients are co-managed with the doctor they know and trust
- Reduced professional stress resulting from division of responsibilities
- Increased focus on surgical procedures
- Ability to focus on the latest surgical advances
- Reduced general advertising and marketing costs
- Increased consult to surgery conversion rates
- Increased surgical volume
- Increased practice revenue
Legal & Statutory Aspects
Co-Management of Surgical Care (Legal Aspects)
Benjamin Eye Institute is committed to complying with specific statues and regulations governing the practice of medicine and optometry. With this in mind we have created this manual of our co-management process to ensure the decision to co-manage is a result of a determination of what is best for the patient and not economic considerations.
Of course, if co-management is done on a routine basis for predominantly financial reasons, it represents unethical behavior. All parties involved in this process must understand and agree that above all else, patient’s interest must never be compromised as a result of co-management.
Co-management is defined as the sharing of postoperative responsibilities between the operating surgeon and another provider. If co-management of surgical patients is being considered, justifiable circumstances* should exist.
Co-management requires a written transfer agreement** between the surgeon and the receiving doctor. The receiving doctor cannot bill*** for any part of the service included in the global period until he or she has provided at least one service. Specific modifiers must be used on claims (54 and 55).
Situations that arise where surgeon concludes the delegation of postoperative care is in the patient’s best interest. The patient must voluntarily consent to this in writing. Justifiable circumstances include: surgeon taking leave of absence, patient is unable to travel, large distance between patient’s home and surgeon’s office, patient voluntarily wishes to be followed by another provider. Co-management is not to be done as a matter of routine policy on all patients.
A transfer agreement between the surgeon and the receiving doctor (optometrist) contains the surgeon’s discharge instructions and effective transfer date. A unique transfer agreement should be constructed for each patient.
For overlapping postoperative co-management of 2nd eye, if the surgeon has transferred care for the first operated eye prior to the second surgical procedure, then two transfer letters must exist. The patient must be reassured that he or she has access to the surgeon, if necessary at no additional cost.
Modifier 54 is used to designate the surgical event; Modifier 55 is used with the claims for postoperative care. 66984-55 postoperative care by the receiving doctor/co-manager.
Co-management is working together and relies upon effective communication in both directions. There needs to be coordination between the surgeon and the receiving office to make sure all pre-operative requirements are met and all post-op days are accounted for.
Cataract & Refractive Lensectomy Guidelines
Cataract Preoperative Evaluation
Patients who are determined to have a visually significant cataract that is affecting the patient’s ability to perform daily activities can be referred to Dr. Benjamin for a pre-operative consultation.
During that visit, in addition to the examination, Dr. Benjamin will go over the risks and benefits of cataract surgery and have an operative consent signed.
The patient is usually set up for another visit to have biometrics performed:
- IOL Master
- Visual Field Testing
- Corneal Topography
- Corneal Pachymetry
This will assist in choosing the proper intraocular lens calculations.
Logistical aspects of the surgery as well as medications are discussed.
Counseling includes a discussion of the expectations concerning best corrected visual acuity (BCVA), including pre-operative conditions that may prevent perfect results, such as age-related macular degeneration.
Counseling regarding uncorrected visual acuity (UCVA) may address goals of surgery, i.e. plano for distance or being left moderately nearsighted to allow near work to be performed without correction. Realistic expectations are discussed.
Patients with high amounts of astigmatism may not be able to rid themselves entirely of glasses. Discussion regarding possible treatment modalities for astigmatism, including LRI and/or Toric IOL’s.
Possible upgrade to a multifocal/accomodating lens implants may be considered if the patient desires.
The primary indication for cataract surgery is decreased vision or glare from cataract formation causing a decreased ability to perform daily activities. Other indications may be traumatic injury to the lens, phacomorphic glaucoma, and phacolytic glaucoma.
Surgery is performed under topical anesthesia with intravenous sedation resulting in minimal patient discomfort. Mild discomfort for the first 24 hours is typical, but severe pain would be extremely unusual. Since refractive lensectomy is essentially the same as cataract surgery, the same risks apply. These risks include, but are not limited to:
- Infection, which if serious can lead to complete loss of vision
- Swelling in the central area of the retina, cystoid macular edema, which usually improves with time
- Clouding of the outer layer of the eye, corneal edema, which typically resolves, but in rare cases requires correction with corneal transplantation
- Detachment of the retina (particularly in highly near-sighted eyes); retinal detachment is usually repaired
- Increased astigmatism
- Inaccuracy of the intraocular lens power
- Decentration of the intraocular lens, which may provide unwanted images and increased glare
- Development of increased pressure in the eye (glaucoma)
- The need for a second operation to remove retained lens fragments in very rare cases
Although all of those complications can occur, their incidence following cataract surgery is very low.
Disadvantages of Surgery
- One definite disadvantage that may be more obvious with clear lensectomy (especially in a patient less than 50 years of age), is the loss of the near focusing power of the eye (accommodation). Thus, it must be clearly understood that even with a successful surgery and an accurate intraocular lens calculation targeted to correct the eye’s distance vision, close vision will usually remain blurred, requiring a separate pair of glasses for close and intermediate vision. It may be possible to deliberately correct one of the eyes for close vision instead of distance, which would allow the patient to read without glasses, even though this eye would then be nearsighted and require a corrective lens for distance vision. This combination of a distance eye and reading eye is called monovision. It has been employed quite successfully in many contact lens patients. This option will be discussed and demonstrated by the operating surgeon. A discussion of the multifocal intraocular lenses such as ReSTOR may also be addressed. These lenses require extensive discussion of near, intermediate issues as well as possible induced night vision problems.
- Even with the latest formulas used to evaluate lens implantation power, it is possible to be off on predicted refractive outcome. This is more common in high refractive errors. In the event of a minor error in the calculation, the vision can usually be corrected by a stronger pair of glasses, contact lenses, or the exchange of the implant or the insertion of a second implant in another operation, or possibly laser surgery.
- Since only one eye will undergo surgery at a time, the patient will experience a period of imbalance between the two eyes (anisometropia). This usually cannot be corrected with spectacles because of the marked difference in the prescriptions, so the patient will either temporarily have to wear a contact lens in the non-operatied eye or will function with only one clear eye for distance vision. Surgery in the second eye can usually be accomplished within 1 to 4 weeks, once the first eye is stabilized.
Non-surgical alternatives to clear lens extraction are to continue to wear spectacle lenses or contact lenses. Although there are essentially no risks to wearing glasses, the quality o vision with strong farsighted or nearsighted glasses is not normal because of an enlarged image and a slight decrease in peripheral vision caused by the thickness of the lenses. Although contact lenses provide higher quality and more normal vision, they have a slight risk of complications, especially if they are worn overnight. The risks of contact lenses include: infection, which if involving the central cornea can rarely cause loss of vision; allergies (giant papillary conjunctivitis, GPC) which can make wearing the lenses difficult; mild irritation; and discomfort. Alternatives to cataract surgery includes changing daily activity habits, such as stopping night driving and using better lighting when reading.