SPECIALTY EYE CARE
hospital

Becoming a Hospital-Based Optometrist

Follow these steps to acquire hospital privileges and adjust to this professionally and personally rewarding career choice.

BRIAN KILEY, O.D., WOONSOCKET, R.I.

Joining a hospital staff has been one of the more challenging, yet rewarding, decisions I’ve made as an optometrist. This typically involves sharing the emergency room (ER) call schedule and also seeing in-patient consultations. As the vast majority of these cases are non-surgical, a well-prepared optometrist can provide exceptional patient care in this setting.

Some of the rewards include:

► High reimbursement. Billing for a consultation is typically reimbursed higher than a typical in-office exam. (See the sidebar “Hospital-based Optometry Billing” at the end of this article.)

► Patient appreciation. Because of the challenging nature of hospital consults (especially patients who have stroke and neurological problems), the treatment may not provide immediate gratification for patients. In most cases, they are grateful to hear what happened and what to expect. In addition, patients are comforted by a familiar face, so they will be even more appreciative if you know them from your own office.

► Healthcare professional networking. Hospital staff meetings have enabled me to get to know other healthcare providers in my area and explain to them what I do. This has resulted in mutual referrals.

Here I explain the keys to becoming a hospital-based O.D.

Acquire hospital privileges.

Follow these steps to acquire hospital privileges.

1. Choose a hospital. If possible, select the hospital closest to your office. This increases the likelihood you will see your own patients and limit the time out of your office when called to the hospital. In addition, look for a hospital that has more perceived need for your services, which makes gaining privileges easier. For example, the first hospital we joined was further from our office but very receptive, due to their lack of eye doctors on staff. Once we proved our competency, it was easier to join a closer hospital.

2. Contact the hospital. Send a letter of request and a copy of your CV to your hospital’s medical staff office. This letter should include your willingness to cover an on-call schedule and any other benefits you would bring to the hospital staff, and areas of specialty training, such as low vision or ocular disease. As you may be the first O.D. to apply to your local hospital, be clear that you are applying for “other professional staff with optometry privileges.”

3. Fill out the application. The hospital should mail you the application after the president approves your letter. This lengthy process includes a thorough gathering of your credentials, such as:

► Malpractice insurance license and DEA number

► Names and contact information for your optometry school

► Externship and residencies that you completed.

► Written responses from your references, your optometry school and a contact person to verify all advanced training (residency and externships)

► Proof of immunizations, including rubeola (measles), PPD, hepatitis B and Tdap (tetanus, diphtheria, pertussis)

► Copy of your malpractice insurance. (Ask your malpractice insurer if you are specifically covered to work outside your office.)

Also, plan time for the reading and acknowledgement of many hospital policies, rules and regulations, pharmacy policy, pain assessment policy and disclosure of any conflict of interests.

A piece of the application that may be daunting is a privilege profile. If no other optometrists are on staff at the hospital, you may need to explain the privileges for which you are applying. (See “Delineation of Privileges,” page 67.)

4. Submit the application. Send the completed application to the medical staff office, so they can confirm accuracy. Application approval can take up to four months depending on the extent of your clinical history. (In an ideal situation, the chief of staff is an ophthalmologist with whom you’ve comanaged and is familiar with your competency.)

Once the application gets approval from the chief of staff, it goes to a credentialing committee, and a letter is sent confirming privileges.

Meet potential challenges.

The three associated with hospital-based optometry:

1. Balancing time between your practice and the hospital. Your services are required for in-patient consultations. These patients have been admitted for a problem unrelated to the eye, though are now experiencing ocular complaints. You must visit these patients within 72 hours of initiation.

We send one of our doctors to the hospital in the morning before coming to the office. As we receive calls regarding consults, we know ahead of time whether the trip to the hospital is necessary, so this prevents multiple trips.

If seeing patients before your scheduled clinic hours is not an option, consider seeing consults during regularly scheduled lunch breaks or after hours. Due to the unpredictable nature of hospital consults, it is difficult to plan time for them. Scheduling time into your office hours can lead to unused time slots and frustration.

In addition, you must write a letter, or communicate the details of the visit with the patient’s primary eyecare provider. Because our office electronic health record (EHR) is not linked to the hospital system, we perform all our charting at the hospital on paper and then input it into our office system to facilitate correspondence. Assigning a staff member to this task or having an EHR that is integrated with the hospital EHR saves time.

2. Treating emergency patients. You will receive calls from the ER indicating a patient has presented with ocular complaints, and they can be sent immediately to your office. If the emergency is not strictly ocular and the patient cannot be moved, you should make every effort to get to the ER quickly.

Train staff to explain any delays to scheduled patients in cases you need to leave for the ER during scheduled clinic times. Our staff has been trained to do so. Patients generally understand that doctors do have emergencies outside their control and will wait for them or reschedule.

The vast majority of ER doctors are extremely thorough in explaining the exact situation and level of urgency. They may have a plan in mind but feel more comfortable talking to you first. Patients who are injured outside our scope of practice are immediately referred to the nearest hospital with ophthalmology residents.

3. Adjusting to hospital environment. You are most likely comfortable with the vast array of equipment in your office. However, some hospitals have more equipment than others, so it can be challenging transitioning to the hospital. To solve this, bring a bag with the tools you may need for a consult. The most commonly used equipment you will need includes:

► Direct ophthalmoscope

► Near-point card

► Bandage contact lens

► Amsler grid

► Dilating drops

► Reference materials

Even if the hospital has some of this equipment, it may be dated, and you won’t be unfamiliar with it.

In addition, hospitals have slightly different abbreviations in charts or formularies for prescriptions, but these are usually reviewed during the orientation process.

Keep in mind: Hospitals never allow sample medication. Even artificial tears need to be ordered from the hospital pharmacy.

To solve this challenge, ask for the abbreviations upfront and the hospital’s policy on sample meds.

Make your choice.

Becoming involved with hospital eye care is an exciting endeavor for us as optometrists.

The early learning curve may seem daunting, but the rewards are worthwhile. Not only will you benefit, but you will also make a significant impact on patient care. OM

Hospital-based Optometry Billing

The ICD 9 codes for the hospital are the same as you would use in your office depending on the diagnosis the CPT codes for consults and inpatient visits are slightly different (listed below).

There are essential 3 sets of codes:

1. Medicare inpatient codes.
2. Private insurers consultation codes.
3. Emergency room codes.

The CPT codes for inpatient consultations are still 99251-99255, and the AMA's CPT book still recognizes consultation codes. But the CMS eliminated the use of both outpatient consult codes (9924199245) and inpatient consult codes (99251-99255) as of Jan. 1, 2010.

According to the CMS, you should be using the initial inpatient visit codes 99221-99223 at the appropriate level (1 through 3) for any initial evaluation of an admitted Medicare patient. For your non-Medicare patients, however, you can still use the consultation codes listed in the CPT book if you provide a consult. Some private insurers are still paying them.

Here are the inpatient consultation codes:

99251

Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient's hospital floor or unit.

99252

Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

99253

Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit.

99254

Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit.

99255

Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient's hospital floor or unit.

If the patient doesn't require an admission to the inpatient facility, the doctor should bill the visit as an emergency department visit using CPT codes 99281-99285 at the appropriate level (1 through 5).

Dr. Kiley practices at Atlantic Family Eye Care. He is on the medical staff and has hospital privileges at the Rehabilitation Hospital of Rhode Island and Landmark Medical Center. Also, he is an adjunct professor of optometry at the Massachusetts College of Pharmacy and Health Sciences. E-mail him at b_kiley@hotmail.com, or send comments to optometricmanagement@gmail.com.