Read more from Practicing Medical Optometry:

• Diabetes: The Other Pandemic
• Diagnose Diabetic Eye Disease
• Treat Diabetic Eye Disease
• BONUS: Zoom Out on Diabetes

Given that 10.5% of the U.S. population has diabetes and that 1.5 million Americans are diagnosed with the disease every year, according to the American Diabetes Association, it makes sense for primary care optometrists to actively play a role in managing diabetic patients by diagnosing diabetic eye disease; encouraging healthy eating habits, moderate exercise and compliance with systemic medications; and making appropriate referrals to other members of the health care community. That said, to best serve these patients and one’s practice, I’ve established the following protocols and procedures.

1 REVIEW/ESTABLISH CARE PROTOCOLS

First, I recommend O.D.s read the AOA’s Eye Care of the Patient with Diabetes Mellitus, Second Edition, which contains a slew of information on the disease itself, its ocular complications, treatment options, management considerations and more.

Second, I suggest optometrists establish protocols in their own practices to facilitate the use of the guidelines. For example, I recommend having staff ask about diabetes during the patient history and workup portion of their visit. For patients who report having the disease, I suggest following up with pertinent questions about type, severity, duration, complications, medications, treatments, etc. Staff should also query patients about test results they might have, like A1C and blood glucose. I also recommend considering making photography part of your patient workup (more on that later).

During examination, doctors should look for changes in refraction and pay special attention to the examination of the macula and the peripheral retina.

After the exam, doctors should utilize letter templates to quickly fill out a report that can be immediately transmitted to the patient’s primary care provider (PCP) or endocrinologist. (I recommend O.D.s set up letter templates in advance to make this part as efficient as possible.)

2 UTILIZE RELATED TECHNOLOGY

In my practice, I find photography, OCT and electroretinography (ERG) especially useful. (See “Diagnose Diabetic Eye Disease” on p.20 for information on the currently available technology to aid in diagnosis.) There are two types of photos optometrists will likely take of diabetic patients: (1) screening photos and (2) photos to document pathology or abnormality.

Before purchasing any diagnostic instruments, I suggest O.D.s research the return on investment (ROI) by comparing equipment cost to its expected utilization and average reimbursement from the insurance plans they currently accept. ROI can be calculated by estimating the potential income per month (number of photos taken in a month times the fee for the photos), divided by the cost per month (monthly note plus any consumables).

Fundus cameras usually have a good ROI, as fundus photos are almost always covered by a medical payer when documenting pathology or an abnormality, and many patients will self pay for screening photos.

An OCT and an ERG device can similarly offer a good ROI for diabetes care. I recommend having staff research local/national coverage determinations to determine which diagnostic codes are supported by which procedural codes. Pro Tip: O.D.s must have an order for any testing and have an interpretation and report to be reimbursed.

3 MARKET YOUR SERVICES

Start with internal marketing. Specifically, I suggest optometrists inform patients that they provide medical eye care when talking to them, and include information about it on the practice website, in brochures and on business cards (specifics below). If you look at the patient’s chart and see a history of diabetes in the patient’s family, mention that you can identify and monitor ocular pathology related to diabetes.

Ask to scan their medical insurance card when checking patients in. Doing so can let patients know that you treat medical disease, let you know which plans are active in your market and help determine which plans you might want to be a provider for.

For external marketing, include the phrase “treatment of eye disease” on your practice website, brochures and business cards. List examples of diseases that you diagnose and/or manage. I also recommend optometrists reach out to local endocrinologists and primary care providers, as they need these eye exams for their HEDIS performance scores. We have tried various methods for this in the past, including cold calling, sending a packet with my CV and the services we offer, but by far the most effective marketing has been sending reports to the provider who manages the patient’s systemic disease.

Correspondence with the patient’s other health care providers is vital. Doing so helps each provider offer the best care possible; it promotes coordination of care and documentation of care for the patient; it often fulfills a requirement of the insurance plan; it elevates our status as medical providers in the patient’s eyes; and it can be a huge practice builder, as providers who receive those letters promptly and consistently are much more likely to refer diabetic patients to us, as well as patients who have other medical eye problems. As mentioned earlier, an easy way to approach this is to automate reports.

Specifically, I recommend optometrists build a template that is easy to complete or use the automated features in their EHR system, if available. I recommend optometrists ask the patient "who is treating you for diabetes?" and to be sure to send a report to everyone they list. In addition, I suggest O.D.s complete these reports as part of the exam, so that they do not forget to do it later (automation makes this easy).

4 CODE CORRECTLY

Proper coding starts with a properly documented reason for the visit (i.e. a chief compliant). This part of the documentation is critical in deciding how to bill, as well as which plan (vision or medical) to submit the claim to. Optometrists should remember the reason for the visit, not what is found during examination, dictates coding. Some specific items to keep in mind:

• There is not a defined “diabetic eye exam” in Medicare or medical plans. Medicare covers what it refers to as a “Special Eye Exam” or a “Wellness” exam for diabetic patients, and many medical plans cover wellness care too. In these cases, an example chief complaint: “Dr. Smith requests ocular evaluation for potential complications from diabetes.”
• Even with a valid medical chief complaint, patients can still determine which plan is billed. For patients who have medical and vision coverage, it is always the patient’s choice as to which plan optometrists bill. The O.D. or staff should be prepared to discuss with the patient which plan would be most appropriate to bill, but it is still the patient’s choice. If a patient insists on using their vision plan, even when there is also a medical reason for the visit, I will generally do so, unless the presenting medical condition prevents me from conducting a proper comprehensive vision exam (wellness care).
  If the presenting medical con-dition prevents this, I explain to patients and bill their medical insurance. If a diabetic patient’s reason for the visit is just “glasses” or “to get more contact lenses” and they do not want to use their medical insurance, that is their right. I would still perform a comprehensive exam, dilate them, send a letter to their PCP/endocrinologist and bill the exam to their vision plan.
• Know the codes. Whether billing the medical insurance or vision plan, I suggest O.D.s know each insurer’s documentation requirements and preference for coding. We each have a finite number of plans we take in our practice. Knowing the requirements for each will prevent a lot of billing headaches, prevent audit recoupment and make conversations easier with patients. I have found that it’s easy to put together a spreadsheet (see "Insurance Coverage Table," p.32) to help you keep track of plan rules and requirements.
  I have discovered that the American Medical Association CPT definitions are a good reference, but we need to keep in mind that some vision care plans have more detailed requirements than those of Medicare and/or the CPT code descriptions. Thus, it is important to review all provider's contracts.
  Generally, the 920X4 codes are an excellent choice for both vision and medical payers, but some medical plans only recognize the 99XXX codes to indicate an eye exam has been performed for the diabetic patient and will try to schedule patients coded with a 92XXX code to ophthalmology for their diabetic eye exam. Similarly, billing the patient’s vision plan for the wellness exam may still require scheduling an eye exam under their medical plan.

5 FOLLOW-UP ACCORDINGLY

The AOA’s Evidence-Based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus, Second Edition, recommendations for follow-up are listed here for easy access:

• No DR/mild NPDR annual dilated eye examination (if no DME or coincident medical risk factors).
  → If DME or medical risk factors are present, follow-up every 4 to 6 months.
  → If clinically significant macular edema (CSME) is present, follow up every 1 to 3 months.
• Moderate NPDR
  → Reexamination in 6 to 9 months (in the absence of DME or complicating medical risk factors).
  → If DME is present, follow-up every 4 to 6 months.
  → When CSME is present, follow-up every 1 to 3 months.
• Severe or Very Severe NPDR
  → Follow-up every 3 to 4 months in consultation with a retinal ophthalmologist.
  → If macular edema is present, follow-up every 1 to 3 months.
• PDR
  → Consultation with an ophthalmologist.
  → Follow-up every 3 to 4 months.
• High Risk PDR
  → Follow-up every 2 to 3 months, or as determined by the treating ophthalmologist.

Follow-up can be more frequent for proper management of the retinopathy, if required.

Patient education and written communication with the patient’s PCP are integral to management of diabetic retinopathy. OM

DR. CASS is a full-time associate with MyEyeDr. in Beaumont, Texas, a past president of the Texas Optometric Association and continues to serve on their third party, legal and legislative, and finance committees. He is also the vice president of Practice Compliance Solutions, a, partner in EDO labs in Dallas, a clinical researcher for Alcon and an auditor for Medicaid. He is a nationally recognized speaker on topics of billing, compliance, practice management and anterior segment disease. Email Peter@PCScomply.com.