Diagnostic Instrumentation

Digital Retinal Imaging: Practice-Building Investment

By Brian Chou, OD, FAAO

Investing in digital retinal imaging instruments offers entrée into new treatment areas—and pays dividends right from the start. Here are the numbers on making it work.

Digital retinal imaging is becoming commonplace in optometric offices. As with digital cameras that are now used everywhere, you can instantly view images, manipulate and transmit images, and take lots of images without the cost of film. These benefits make investing in one of these instruments something your practice should consider.

Synmed CR2 camera
courtesy Synemed, David Whalen

Calculating Revenue-Boosting Potential
The practice can charge an additional fee for digital retinal imaging performed for screening during routine examinations. Charges of $30 to $60 for screening retinal photography are common. These fees are not generally covered by third-party payers. I know of practices in which over 80 percent of patients agree to have digital retinal imaging despite the added cost. To explain to patients what they get in exchange for the added cost, you might say: “Digital retinal imaging is my preferred method for evaluating the inside of the eye because it’s a permanent record and I have it to compare against in the future. Although I’d like to review the images, you should know that your vision plan does not pay the $XX fee, so you’d be responsible for it.” ROB editors note: If you are a participating provider for a third party, protect yourself by having a signed ABN (Advance Beneficiary Notice) when charging patients for non-covered services or materials.

Code as Medical Eyecare
ODs can bill medical insurance for digital retinal imaging when there is necessity for documentation and an appropriate ICD code. The possible CPT codes for billing are 92250 (fundus photography with interpretation and report), 92225 (extended ophthalmoscopy), and 92226 (extended ophthalmoscopy, subsequent). However, if a practitioner is using the retinal camera for both screening purposes and medical billing, there should be some software function that differentiates the two. For example, the Optos units have a screening function, and also a billing function called Optomap Plus. The Synemed retinal imaging system using the Canon CR2 camera has an analogous software function. ROB editors note: Some third parties only pay for a medical photo if there is a medical reason for the office visit. In these cases, schedule the patient back for the medical photo.

CenterVue DRS

Incorporate With No Added Charge to Patient
When used for screening purposes, one drawback to asking each patient whether they would like digital retinal imaging and would accept an extra charge for the service is some patients may feel like they are being sold something extra and unnecessary and getting “nickeled and dimed.” The lack of consistent acceptance reduces procedural efficiency in the office. For that reason there are some practices (like mine) that incorporate digital retinal imaging into the routine examination at no additional cost to the patient.

If you choose to not charge the patient extra for digital retinal imaging, you do not need to raise the cost of your comprehensive examination. In my case, the cost of the retinal imaging is “financed” by:

1. Better operational efficiency of the practice and reduced frequency of dilation (yielding increased capacity to see more patients, and patients that are more likely to purchase eyeglasses the same day rather than come back when not dilated).

2. Patient perception that the practice is cutting edge by incorporation of the technology and word-of-mouth recommendation to friends and family.

Increase Perception of Examination Value
Most of the digital retinal cameras take a 45 degree field of view in the eye. The notable exception are the retinal cameras made by Optos, which can image up to 200 degrees of retina (about 78 percent of the retinal area). The benefits include photo-documentation for future comparison and the ability to examine the tissue while simultaneously showing the patient what’s evaluated. When you make digital retinal imaging a regular part of every comprehensive examination, patient perception and sense of value increases because they recognize that there is economic value to the retinal imaging and that they are getting the measurement done complimentarily, which encourages their return visits and recommendation to friends and family. A practice that takes this approach can still bill medical insurance for non-screening photography if they have the right retinal camera system–like Optos and Synemed. My office has two of the Synemed Canon CR2 cameras, which cost $24,000 each.

Economical Choices to Enable Universal Screening
Screening all patients with no additional charge is becoming more economically feasible, with low-cost retinal cameras, like the CenterVue DRS ($14,000). But I don’t think it is economically feasible with cameras such as the Optos unit for which some offices are paying close to a $20 use-fee per patient. Users can also purchase the Optos P200 units for about $80,000, which is too costly to allow most practitioners to absorb performing screening imaging at no additional fee.

There are several lower-cost options. A neat one is EyeQuick, which soon will be available for $5,995. EyeQuick may have more use for primary care settings and veterinary, but at least some eyecare practices will find it valuable because it is the lowest cost digital retinal camera which allows a practitioner to bill medical insurance. There is also the OIS EyeScan camera, which costs approximately $20,000.It offers a 35 degree field of view. One of its main features is portability and modular use. Note that the aforementioned costs cited for various imaging systems are approximate, since it varies depending on whether the system comes with a computer, software, an instrument table, shipping and handling, etc. OIS recently was acquired by Merge Healthcare.

ROB Editors note: Your strategy for a per-use fee may change with managed care patients who have fixed reimbursements. You cannot include a per-use fee test if you are losing $20 each time you perform it.

Present vs. Future Value
Make sure you are buying present value and not future promise. What I mean by that is if you have two comparable retinal imaging systems where one of them currently integrates with your electronic health record system but the other one does not but promises to do so, obviously the one that currently integrates is preferable. Second, don’t forget to consider the maintenance service agreement. One of the retinal cameras has a service agreement that costs $10,000 a year, partially because the camera is so large and bulky that it cannot be readily transported, thereby requiring trained service technicians to come on-site. Third, remember that low cost becomes too expensive if the instrument and system does not do what you want. There is a significant difference in image quality and function between some of the retinal camera systems.

Check for Ease-of-Use
Most of the new cameras are quite easy to operate, which is important because image capture is typically delegated to ancillary staff. In fact, the CenterVue DRS camera is so easy to operate, it is virtually self-administrable. I’ve seen a demo of it, and because the measurement is automated (autofocus, auto-alignment, auto-capture) a junior high school student could probably figure it out. Others require more learning but in all cases, the training for image capture is usually minimal. Doctors also have to learn how to use the image review software.

Minimal Time Investment
If digital retinal imaging is done as part of the routine exam, it probably takes staff between two and five additional minutes during preliminary measurements, depending on the system used and staff proficiency. The most efficient systems have capture and review software that integrates into the commonly used electronic medical records, saving the need for double entry. On the back-end, digital retinal imaging saves the doctor several minutes per patient, as it provides them with information about eye health more easily than relying solely on dilation. Digital retinal imaging during routine examination can reduce the frequency of dilated fundus examination, though it certainly does not replace it. The benefit of reduced frequency of dilation is that patients don’t have to spend as much time in the office. ROB editors note: The gold standard for an eye exam contains a dilated fundus exam. No matter what the marketing materials say, clearly understand your legal exposure if deciding to forgo a dilated fundus exam.

Improve Patient Eye Health With Additional Screening
Patients appreciate seeing their conditions or lack thereof in the photographs. I’ve found digital retinal imaging helpful for gaining patient adherence to treatment, particularly if they have signs of diabetic retinopathy, macular degeneration and other conditions. I think consumers are becoming more skeptical of their doctors’ advice, relying more on their own online research. If a mechanic finds a problem with a car, many owners would want to know the problem really exists–and that the problem was not contrived to gain the sale of unnecessary work–before spending more money. The beauty of retinal imaging is that an imaged eye condition reinforces to the patient that the condition is real and that the doctor’s recommendation should be followed.

Investing in digital retinal imaging can serve your patients better by spotting eye health conditions faster and by reminding patients of the full value of their annual examination.

Digital Retinal Imaging Resources

A recent article by Dr. Chou on Optomap and dilation:
http://journals.lww.com/optvissci/fulltext/2003/10000/limitations_of_the_panoramic_200_optomap.7

For those who plan to use the instrument mainly for medical billing, this worksheet is helpful:
http://www.calcoastophthalmic.com/pdf/costanalysis.pdf.

Related ROB Articles

EyeMed Vision Care Adds Retinal Imaging Benefit

Do You Have the Tools Needed to Diagnose Glaucoma

Medical Eyecare Opportunity in Optometric Practice

Brian Chou, OD, FAAO, is joining EyeLux Optometry, which opens fall 2011. He is a former partner of Carmel Mountain Vision Care in San Diego, Calif., where he practiced for 11 years. To contact him: chou@refractivesource.com chou@refractivesource.com.

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