for Eyecare Practice
your instruments can benefit both your patients and your bottom line.
By Clint Cappelle
practitioners face many challenges on a daily basis, some that originate from outside
of the practice and some from within. In my years of visiting many optometric practices
around the country, I've observed and learned from some very talented clinicians
and gifted business owners.
I've also learned and personally observed
what is not usually successful in eyecare practice. How you manage these
daily external and internal challenges is usually visible the instant patients walk
in your door, and it will continue to leave an impression on them throughout their
Figure 1. Corneal topography image of keratoconus.
Build Value into Your Practice
You can be the most gifted clinician around, but
that won't necessarily get patients in the door and keep them coming back. The most
successful practitioners I know are very talented at building value into every aspect
of their practice.
Diagnostic equipment is one tool you can use
to build value into the examination you perform on your patients. I'll describe
some of the clinical and financial benefits that diagnostic equipment can provide
for you and your patients.
They come in many forms, but perimeters are a
must for all practices. Clinically, a perimeter is an extremely valuable tool for
your practice. The question you should ask yourself is: Am I using my perimeter
to its fullest potential?
Following are my recommendations for your
practice. You need a good screening perimeter, and it needs to be fast and accurate
no more than two minutes per eye in screening mode, with excellent sensitivity
and specificity values. (Ask company representatives to show you that information.)
I highly recommend that you present every new patient and every established patient
returning for yearly or bi-yearly examination with the option to perform the test.
Automated screening peri-metry is beyond what some insurers require for payment.
They may require only a confrontation peripheral visual field test and/or amsler
grid. Practitioners should consider whether or not they will charge for this service
beyond their comprehensive examination or other examination fee. Too many doctors
have told me how pleased they are with the success of a screening perimeter in their
office for it to not be true. Please remember, it's in your patients' best interest
to have the test done, and the first time you find something that you otherwise
most likely would have missed, the instrument pays for itself.
If you treat glaucoma or aspire to treat it, a
good thresholding perimeter is a requirement. You'll need an instrument that is
able to perform at least a 30 degree test. Pay close attention to how the instrument
gathers the information, and what it does with the data once obtained. You have
many options for thresholding perimeters. Projection, StaticLED and Frequency Doubling
are the most popular. Each has its own positives and negatives, and you need to
determine which will benefit your practice and your patients the most, both today
and in the future. Don't make the mistake of filling a temporary gap today only
to find that you have a hole in the future. Purchase for where you are today and
where you will be in the future.
If you are in the market for a perimeter or
are contemplating trading in your old one, ask yourself this question: Am I treating
or will I be treating glaucoma? If not, your best option may be a perimeter that
isn't full-featured. If you are treating glaucoma or have intentions too,
I recommend that you consider a full-featured model. Which one is the best? The
one that fits your needs and provides reliable, accurate information. Talk to your
peers and to the doctor to whom you refer the most to assist you with your choice.
Figure 2. Pseudomonal
corneal ulcer image taken with a digital photo slit lamp system.
Efficiency, efficiency, efficiency that's
the name of the game when choosing an auto-refractor. How do you know if you're
a candidate for purchasing one or if you're using your current auto-refractor to
its fullest potential? In an ideal situation, I recommend the following approach:
First, don't run it yourself. Train someone in your office to run it. Most current
auto-refractors are very user friendly and accurate to about ±0.50D, depending
on the age and accommodative ability of the patient. If your unit has visual acuity
capabilities, train your staff to do this also. Instruct your staff to enter the
refraction from the unit into your phoroptor. You can now spend more time attending
to patients' needs, rather than gathering information that others can obtain. Efficiently
managing your resources will provide the opportunity to spend more quality time
with patients while managing more patients per day.
I believe about 25 models of auto-refractors
are currently on the market. I recommend a unit with fast acquisition speed, auto-tracking
and alignment, pupilometer and visual acuity measurements with subjective refinement.
I know that's a lot to ask for in an auto-refractor, but such models do exist and
are very useful to maximize your time.
Corneal topography may be more difficult to justify
for a small practice, but sometimes you need to dig just a little deeper. Clinically,
the benefits of topography are fairly straightforward. Keratoconus (Figure 1), pellucid
degeneration and even elevated levels of post-surgical astigmatism are all acceptable
and billable diagnoses.
billing out and receiving payment for corneal topography is somewhat difficult.
You need to bill it out under the 92499 unlisted code and send the proper required
documentation. It's my understanding that corneal topography will have its own procedure
code beginning in January 2007. This should make the medical billing for topography
much easier and help clear up the blurry lines of what is an approved diagnosis
code and what is not.
You can't effectively screen
and comanage refractive surgery patients without corneal topography, and it's an
excellent way to introduce refractive surgery to your patients. The bulk of your
patients who are candidates for refractive surgery are your contact lens patients,
so it makes sense to perform topography on all of them. There are several schools
of thought as to the proper implementation model for corneal topography. One way
is to offer it as a fee for value added service and charge a nominal fee for the
test. I don't feel this is the best way to promote topography in your practice,
especially if you're currently offering screening visual fields in this manner.
I suggest you instead perform topography on all of your contact lens patients and
increase your contact lens fitting fee. This way you perform it on the patients
who will potentially benefit the most from it.
I also recommend printing out an extra
copy of the exam report and giving it to the patient to take home. This will add
value to the experience your patient has while in your practice and will help improve
retention rates because it demonstrates that you have a progressive, hi-tech, advanced
practice that provides the highest level of care possible.
If you're contemplating the purchase
of a new topographer or trading in your old one, you may find several diagnostic
tools that some topographers provide valuable. All topographers can perform axial
and tangential maps fairly accurately; what all topographers can't do is
elevation mapping, in which the topography software fits a patient's cornea with
a best-fit reference sphere and then calculates the patient's corneal elevation
to that reference sphere. A common mistake I've observed in practice is when clinicians
misinterpret corneal steepness for corneal elevation. If a part of the cornea is
steep, that doesn't necessarily mean it's elevated.
The software programs available today
will show you corneal elevation based on a reference sphere and corneal irregularity
based on a best-fit reference toric. Instead of fitting the cornea with a best-fit
sphere, the software will fit the cornea with a best-fit reference toric, a hypothetical
best-fit lens for the eye, and it will show you the residual corneal irregularity
that spectacles or toric contact lenses can't correct. This could help you determine
why your 20/25 or 20/30 patient doesn't have acuity of 20/20. In most cases, a simple
axial map would not be able to clarify this for you, unless the condition was very
Figure 3. Papilledema
image taken with a non-mydriatic digital photography system.
In the past three years, the usage of retinal
imaging has grown significantly within eye care. The HRT II (Heidelberg Engineering),
GDx VCC (Carl Zeiss Meditec AG) and Stratus OCT (formerly OCT 3, Carl Zeiss Meditec
AG) have shown themselves to be the leaders in this area. Although they all use
completely different technology to gather the data, the goal of objectively measuring
and detecting structural loss to aid in the diagnosis and management of glaucoma
and macular changes remains.
The most common question I receive about these
devices is not "Should I get one?" but "Which is the best one for my practice?"
That's usually a fairly difficult question to answer. All of the technologies have
proven to work. Some are more user friendly than others, but the qualities that
make them user friendly limit their versatility. Having the instruments demonstrated
in your practice will assist you with the decision. Make sure your staff is present
during the demonstration and that they use the instrument themselves. Will they
be able to perform the testing needed without help from you? Remember, you use the
information presented to you by your staff to make clinical choices for your patients.
You must have full confidence in the information.
Slit Lamp Photography
Digital photodocumentation is one of the most
overlooked and powerful communication tools available for practitioners today. It
provides your patients the opportunity to visualize the damage/condition that they
are confronting and may encourage greater patient compliance. For example, seeing
an image of a corneal ulcer (Figure 2) generated by poor contact lens maintenance
will remind a patient to remove and properly clean his lenses. Billing and coding
for photodocumentation is well defined, and you should use it as necessary.
Retinal photography is another well-established
procedure commonly used to verify retinal health or to visually document a specific
retinal abnormality. It's very common for practitioners to offer or suggest this
procedure for an additional fee. With the evolution of non-mydriatic digital photography
systems, retinal photography is very user friendly and cost effective. Figure 1
shows an example of papilledema taken with this system. If you're currently using
an old Polaroid system, I suggest considering the addition of a digital portion
to your current system or trading in your current system for a new one. The cost
of Polaroid film is astronomical, and it's becoming more difficult to find.
Legally, digital posterior pole photography
is one of the smartest choices you can make to protect yourself against malpractice
accusations. A digital photograph of the eye on a specific examination date is objective
evidence of the health of the eye at that time. The value of a simple digital photograph
could become priceless one day. Typically, medical billing for optic nerve photographs
is yearly for glaucoma suspect patients.
Always Put Your Patients First
I want to emphasize that every point I've discussed
in this article has your patients' best interests in mind. For example, I've personally
seen the benefits of performing a screening visual field on every patient. It's
well worth the effort to find a potentially life-threatening condition that might
otherwise go undetected.
It is also in your patients' best interest
for you to be efficient. Their time is valuable and, more importantly, the time
they spend with you is valuable. The best way to achieve this level of efficiency
is through automation. You can't do it all. If you properly build value into your
exam, you'll have a more successful business and clinically, you'll have
the data you need to properly manage your patients. Your patients in turn will appreciate
your thoroughness and will return year after year.
Mr. Cappelle is the Ocular Disease Service and Imaging Coordinator at the Ohio
State University College of Optometry.
Contact Lens Spectrum, Issue: December 2006