This article will review clinical, business and legal aspects of cataract co-management...doctors who have had experience in this field may still gain a few pearls.

Thanks to AOA advocacy, CMS allows optometrists to bill for cataract post-operative services using a modifier system.  In the next two years, CMS is doing away with the concept of post-op periods for all surgeries.  Procedures with 10-day post-op periods will be discontinued in 2017 and procedures such as cataract with 90-day periods will be discontinued the following year.  Post-operative care will become a separate billable event but the actual replacement system has not yet been published. We will keep you informed as these changes occur.

Post-op care is a patient-directed choice.  Optometrists should discuss the option with the patient and indicate the patient's choice for care on the referral form.  CEC's referring optometrists range in care dates from the last 60 days to a few who provide all 90 days of care.  Patients sign an agreement as part of the scheduling process expressing their choice.  Our consult reports include dates of surgery and a recognition of the length of post-operative care;  any other arrangement between the surgeon and the referring doctor is fraudulent and can result in fines and loss of Medicare participation.  If you are billing Medicare and do not receive Medicare payment for post-operative care, it is imperative that you contact our office so that we can help rectify the problem.

Our recommended standard post-operative visits are as follows:

• Obtain uncorrected and pinhole vision
• Slit lamp examination and intraocular pressure using a fluorescein strip and anesthetic bottle that is not used for other patient contact
• Review of post-operative instructions including: 

• Topical medications of Ofloxacin q.i.d. x one week

• Pred Forte q.i.d x four weeks

Post-op instruction sheets are available from CEC to put on your letterhead.

One-Week Post-Op Visit

• Visual acuity and refraction, if vision is below what is expected.
• Slit lamp examination and IOP.

If the second eye is already tentatively scheduled, confirmation to move forward with surgery, as well as patient's lens choice, are documented.

Final Post-Op Visit 3 weeks or later

• Vision refraction, if necessary
• Slit lamp exam
• Pressure
• Dilated fundus exam.

Because many patients choose consecutive surgery with the eyes booked 2-3 weeks apart, we now see the one-week visit for such patients at CEC.  That way, there is no time lost in communication about choices for the second eye.  The days billed by our office and your office are given on our final notes which usually arrive in your office by fax in the form of a copy of our post-op notes from CEC.

Because of the pre-operative educational time and the post-operative hand-holding, CEC offers a separate co-management program for ReSTOR multifocal lenses.  Because this is not a Medicare-covered service, a global fee is collected from the patient and an optometric co-management fee check is issued directly from Capital Eye Consultants for this portion of care.  Medicare patients are also billed for medical post-operative care, as discussed above.  Optometric co-management centers around the country do not provide extra co-management payment for toric lenses because no extra services are provided by the optometrist.  Pre-operative measurements are very exacting and must be performed in the surgeon's office.  Some surgeons do cut checks to referring doctors for toric patients.  This is very likely inducement to refer, punishable by Federal Statutes.

If you are not actively co-managing cataract patients, you are not taking advantage of hard-won services allowed under Medicare.  Optometrists are uniquely qualified to provide these services, given our clinical training and recognized expertise in patient communication skills.  Patient care is also enhanced by easily accessible care closer to home provided efficiently by someone who knows the patient.  Inter-communication between the surgeon's office and the co-managing doctor is of paramount importance.  Our system has been honed over the years to make that communication as seamless as possible.  We welcome your participation and feed-back.  Remember, this system is in place throughout the U.S. and is probably the best way to deliver cataract surgery.  It utilizes the expertise of the best surgeons in the country, coupled with trained and caring primary care optometrists to provide the clearest choices and the best results for cataract patients.

James E. Powers, O.D.

CEC  To Start Performing Implantable Miniature Telescope (IMT) Surgery

Dr John Baldinger will shortly be performing IMT surgery on patients with advanced macular degeneration with macular scars.  This novel intraocular lens has been available since 2010 (FDA approved), however was only allowed to be performed in a hospital operating room . CMS (Medicare) this year is allowing the implant to be placed in the eye at the time of cataract surgery in a free standing ambulatory surgery center setting, where most cataract surgery in the US  is currently performed. 

Only patients who meet strict criteria, pass pre-surgery tests with an external eye telescope and agree to vision training afterward are eligible. 

The procedure will be performed at the Fairfax Surgical Center in Fairfax Va where Dr. Baldinger has performed over 25,000 procedures since 1986.  We are proud to be the first practice in Northern Virginia to offer this technology

John C Baldinger MD

Denver Academy 2014

I recently attended the Academy meeting in Denver.  Cold was the theme with temperatures as low as -2 degrees.  There were many fine speakers and lectures, but of course I gravitated towards the ocular disease track.