PROFITABILITY IN 2004: Part one of a three-part series.
Reap the Rewards of Primary Eye Care
It's time for optometrists to integrate ocular disease management into their practices. Here's how to market primary care, educate patients and become more profitable.
BY KEN RODDY, O.D., Tulsa, Okla.

For the last 25 years, optometry has fought in the legislative trenches for the right to first use diagnostic pharmaceutical agents and then therapeutic agents. We educated our senators and representatives as to the breadth and scope of our education and explained how we are qualified to treat ocular disease. Some of us received all of the privileges with the stroke of the governor's pen while others were granted these rights in stages.

Now that therapeutic prescribing privileges are present in all 50 states, it's time for optometry to integrate ocular disease management in a profitable way into our practices and to take a more active role in treating our patients and to embrace full-scope practice.

I'll explain how to educate your patients about primary eyecare services and how to market primary care in your practice.

Educating patients

So how do you educate your patients about the primary eyecare services that your office offers? First, put the word out. You can accomplish this in many ways, such as sending a quarterly newsletter to your patient base. (We do this in my practice by trying to run at least one article on primary eye care in our newsletter.) Getting the message to your patients on a regular basis is key because they may not require ocular disease treatment until later.

Other ways to remind patients of the scope of your practice might include speaking to civic groups or creating an information center in your waiting room. Once you begin to incorporate primary care into your practice, it will begin to build on itself both through periodic follow-up visits and through word-of-mouth patient referrals.

Another important way to educate your patients about your services is to sign up for the insurance plans in your area that affect your patient base. If you want to be business savvy, then assess each insurance plan to determine whether it offers appropriate compensation. Remember you can't lose money on every patient and make it up in volume. In the next year, set a goal of being listed as a provider on one to five insurance plans.

Also make an effort to attend optometric education meetings dealing with Medicare coding and billing. Record and submit claims according to the standard of care using either the ICD-9 or CPT codes and bill for all the services you've provided.

Also, consider writing a brief note to the patient's primary care physician outlining the basics of your diagnosis and what treatment you initiated. Following this protocol reminds other healthcare providers that you practice primary eye care and, in my experience, has resulted in many referrals to our office.

To give you a better idea of how to incorporate primary care into your optometric practice, consider the following example.

Offering primary care

Let's say that a patient presents to your office for a routine yearly eye exam. During the course of the exam you discover elevated IOPs and note that the optic nerve cupping is enlarged with apparent thinning of the neuroretinal rim. At this juncture, it's appropriate to give the patient a primary diagnosis of glaucoma suspect and a secondary diagnosis of ocular hypertension.

Because the patient presented for a routine eye exam, it's appropriate to bill her insurance for a comprehensive eye exam (92004). Remember to have the proper documentation that's required to bill for a comprehensive exam. We'll assume a usual and customary fee of $120.

Our next step is to have the patient return for a glaucoma evaluation, which you should schedule for some time other than the day that you perform the original eye examination. When the patient returns, the staff will perform threshold visual fields (92083) and optic nerve head and/or retinal nerve fiber layer analysis (92135). We'll assume the usual and customary fee for these tests are $60 and $120, respectively.

After the staff completes visual fields and optic nerve head and/or retinal nerve fiber layer analysis, the patient is ready to see you again. During this visit it's the standard of care to perform the ancillary tests of gonioscopy (92020) and pachymetry (76514). We'll assume a usual and customary fee of $30 for each of these.

This office visit should also include a detailed health history as well as slit lamp examination, tonometry and evaluation of the posterior pole of the retina. Explain to the patient why you're performing additional tests and what you hope to rule out or accomplish with each. Review with the patient the risk factors that she has for glaucoma as well as the frank findings consistent with glaucoma.

Taking a moment to explain these points helps to alleviate patient fears, instills trust in the patient and is a hallmark of the optometric physician.

Continuing care

In our example, we've determined that the patient has ocular hypertension, enlarged cupping, open angles, abnormal visual fields and/or optic nerve head and nerve fiber layer analysis, so you can make the diagnosis of primary open-angle glaucoma and initiate treatment. Because this is a medical visit, it's most appropriate for you to document either a 99213 or 99214 evaluation and management (E&M) code. Let's assume for this visit that you document a 99214 E&M code with a usual and customary fee of $100. At this point the total bill for this patient is $460.

With the initiation of treatment for primary open-angle glaucoma comes the need for routine follow-up care, which includes monitoring the IOPs and optic nerve heads. After you begin treating glaucoma, have the patient return in one month to assess the efficacy of the medication.

During follow-up visits for glaucoma, you should at least conduct expanded problem-focused histories and delegate acuities and pupils to your staff. You, however, should perform a slit lamp examination, tonometry and posterior pole evaluation (which correspond to 99213 E&M coding). Because of the minimal time required to perform the follow-up examination, you can schedule the patients between general eye exams to maximize your daily schedule.

Follow glaucoma that appears well-controlled at four-month intervals or add three more office visits each year. We'll assume that our usual and customary charge for a 99213 E&M is $60, which totals $240 for the remaining office visits for the year.

Beyond glaucoma

For the first year of our example you can expect to bill $700 to manage the patient's glaucoma. If you expand this number to 10 patients each month, then your gross income will increase by $84,000 in the next year (See the sidebar below).

Remember that these fees have no cost of goods associated with them. Key to the process is the more you're willing to delegate to your staff, the more primary care patients you can see and the greater the increase in gross. You can create examples for other eye diseases such as diabetic retinopathy or conjunctivitis, but realize that filling the empty slots in the day with primary care adds up in the course of a year.

These patients are usually grateful that you diagnosed their condition before they had profound vision loss and typically refer many family and friends to your office who are in need of eye examinations, glasses or contact lenses. Successful business-minded doctors are aware of this and that's why they incorporate primary care into their offices.

Seize all opportunities

Other examples of primary eye care include corneal ulcers, herpes simplex keratitis and acute angle-closure glaucoma. Ocular diseases such as these will typically include a detailed history and examination, but they'll also have "high risk" associated with them in the decision-making process, so you'll most likely grade them as 99215 or 99214 upon initial evaluation and then down grade them with subsequent follow-up visits as the conditions respond to treatment and the risk drops.

Ocular pathology such as bacterial or viral conjunctivitis, episcleritis or keratoconjunctivitis sicca have a more benign course and the history, exam and decision making usually correspond to a 99213. Most conditions will have two or more follow-up visits with the total bill ranging from between $150 and $500+. But remember, these services don't require a cost of goods.

Make the logical choice

Instead of treating your patient's glaucoma, you could refer him to another doctor for the same care, but such a decision is obviously counterproductive to practice growth. The patient may not return to you to purchase eye wear and you'll probably miss out on his referrals to friends and family members.

By referring a patient elsewhere for primary care, not only will you miss out on the financial rewards of actively participating in enhancing his ocular well being, you'll also miss out on the personal satisfaction of diagnosing and treating the disease and consequently improving the patient's quality of life.

You know the feeling of satisfaction you get when you dispense a pair of glasses to a first-time myope and for the first time in a long time notices that the trees have leaves? You can also achieve this type of satisfaction by knowing that in providing primary eye care, you prevented someone else from going blind. So with the new year, let's begin to incorporate primary eye care into our practices and benefit both the patient's vision and our practice's growth.