By Jeanmarie Davis, OD 
Providing care to glaucoma patients allows you to increase the eye health and loyalty of patients, while expanding into the profitable area of medical model optometry.
Creating treatment plans for patients diagnosed with glaucoma not only preserves eye health, it also builds trust, credibility and rapport with patients and their families. You see glaucoma patientsgenerally fourtimes per year, allowing more time to have personal interaction. Plus, treating a sight-threatening disease gives patients confidence in your abilities and loyalty to your practice. In addition to those benefits, overseeing the care of glaucoma patients builds your practice. You generate more in fees and the relationships you build with glaucoma patients leads to referrals.
ROB Bottom Line: Glaucoma Management
(Fortypicalpractice specializing in medical model optometry)
Glaucoma patient visits per week: 40
(10 patient visits forinitial work-up)
(30 patientvisitsfor follow-upand tests)
Total fees initial exam and testing= $405
Total fees,follow-upsandtesting= $599/year
Revenue per patient Year 1=$1,004
Revenueper patientYear 2+ =$640
—ROB Editors
Glaucoma Patients = Medical Eyecare Reimbursement
Reimbursement for glaucoma treatment is higher than reimbursement for many other optometric services because it is considered medical eyecare. Here is a break-out of approximate fees that glaucoma patient treatments and follow-up visits generate, including the appropriate insurance codes. Fees will vary in different areas. Most insurance plans follow Medicare guidelines. Check to see what can be billed on the same date of service before performing that procedure.
Glaucoma screening: (G0117) $51.75
New patient exam: (92004) $83
Established patient exam: (92014) $61
Follow-up visits (fourfollow-up office visits per year@ 5-10 minutes)
Interim office visit: $41
Typical initial work-up includes all:
Gonioscopy: (92020) $25, conductedtwice a year
Visual Field Test: (92083) $88 total(including technical and professional components, conducted twice a year)
Use of scanning computerized ophthalmoscopic diagnosis equipment: (92135) At least $125 (conductedtwice a year)
Taking fundus photos: (92250): $72
Pachymetry: (76514) $11
Initial work-up fees total: $405
Invest in Necessary Instrumentation
Minimum equipment: Gonioscopy lens, slit lamp and Goldmann tonometer–standard for every optometrist to have.
Additional beneficial equipment: Automated Visual Field machine, computerized ophthalmoscopic diagnostic equipment, fundus camera and pachymeter (you can purchase a handheld pachymeter for under $2,000)
Four Best Practices for Managing Glaucoma Patients
1. When a patient with an existing glaucoma diagnosis comes to you ask for copies of all old records. Have the patient bring bottles of their medications to the office. Get a detailed history from the patient. In most cases it is best to have the patient discontinue all medications for two weeks and measure IOP to determine baseline and see how effective current therapy is.
2. Document everything including procedures and conversations.
3. Always see patients AT LEAST every six months, more often if necessary.
4. Remind patients of the serious nature of the disease and the importance of follow-ups and good compliance on a regular basis–not just initially.
Other options are leasing the instruments (less costly) or having an instrumentation vendor bring all the necessary equipment in for a day or two a month and paying for the service. This is commonly done and very convenient. Technicians typically perform all the testing, so the doctor is able to see other patients at the same time. Another option is to send patients to a fellow OD in the area who has the instrumentation just for diagnostic testing. Some of these tests (i.e. visual field) can be coded for the technical component separately from the professional component (interpretation). An OD can write a prescription for exactly the testing necessary. When the patient goes to the other office they don’t even have to see the doctor. They can simply have the technician run the test. Results are sent to the referring OD, with the patient also returning to their doctor for follow-up and results.
Demand for Glaucoma Services
I saw approximately 40 glaucoma patients per week in my South Florida practice. Some were initial work-ups, some included annual visual field/NFL analysis and some were simple follow-up visits. Most states allow ODs to independently diagnose, treat and follow glaucoma patients. However, there are a few states that do require a referral at some point. Any time a patient needs surgery or is not adequately responsive to medical therapy, or continues to progress despite full medical therapy, a referral to a glaucoma specialist is required. Any time there are significant risk factors or for very advanced-stage glaucoma it is always a good idea to have a glaucoma specialist evaluate the patient even if just for consultation. In my practice I did not refer to an ophthalmologist unless the patient needed surgery, was dangerously advanced or I wanted a second opinion to ensure the patient received the most optimal treatment available.
Diagnosis and Treatment Protocol
I would run a full diagnostic evaluation on every patient suspected for glaucoma. Insurance does not allow everything to be done during one visit, so the evaluation occurred over several visits, usually two weeks apart. Once I established the diagnosis and stage (how advanced the disease was) I would calculate a target pressure and initiate medical therapy. I would follow up in two weeks to see how the patient responded to the medication. I would make appropriate changes and follow-up every two weeks until target pressure was achieved and stable. Then I would follow-up every three months at least for the first year. After the first year I would continue to follow-up every three to six months depending on the patient’s disease severity, compliance and risk factors.
Have the Conversation with Patients About Glaucoma Diagnosis
Patients should be educated about the serious nature of this disease and the risk of permanent vision loss without proper follow-up and compliance with therapy. This should be documented in the patient’s record because this conversation and documentation is required by law in some states, and even if it is not required in your state you would want documentation for your own protection. Here is what the conversation might sound like:
Doctor: “Mrs. Smith, glaucoma is a serious disease that can lead to permanent vision loss without proper treatment and regular follow-up evaluation. However, most cases can be treated successfully if you use your medication as directed and return for all of your follow-up visits.”
Patient: “I don’t really understand what this means to me long-term. Is this something that will eventually go away?”
Doctor: “There are many effective medications, some of which I have just prescribed for you, for controlling glaucoma, but this is a disease you will have to continue to have a doctor manage–for the rest of your life.”
Patient: “Well, what if my eye pressure goes back to being normal? Does that mean I’m cured?”
Doctor: “There is not one number that represents normal or good for glaucoma patients and checking eye pressure is not enough. Close follow-up by the OD and regular diagnostic testing are required to determine if current therapy is adequate to prevent progression. There are no symptoms I can tell you to be on the lookout for. But as long as you take the medications I have prescribed and visit us for all of your appointments, you should be fine. We will make sure you receive the best possible care for your glaucoma, so the disease is controlled and you are able to preserve your vision.”
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Jeanmarie Davis, OD, recently joined Alcon’s Global Performance Development department as manager, global performance development. To contact her: drdavis2020@yahoo.com.
