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To manage these patients, clinicians need time to not only examine the patient but also test to establish disease progression. But it’s not as simple as it sounds.
Outcome-based care—for which you need to see the patient less, do less testing and still get measurable results—is the reality of our health care system today. To many, this mandate creates the paradox of the ages for patients who need more specialized care. So, how does this impact your practice as you learn to “re-manage” these disease states?
Efficiency is Important, But Effectiveness More So
Managing these chronic diseases efficiently and effectively is not difficult, just different from what you are doing, or were taught in school.First, you must become familiar with the American Optometric Association’s Clinical Practice Guidelines and the American Academy of Ophthalmology’s Preferred Practice Patterns for the diseases you are managing.2,3 These guidelines provide a protocol of evidence-based medicine. You might be surprised to learn that many of the tests you order don’t necessarily deliver optimal outcomes. Follow-up visits also may be less frequent than you expect. However, you should always provide the specific care that is medically necessary for the individual patient, even if it is in conflict with the respective guidelines.
Outcome-based Coding
Let’s say two ODs are managing their respective patients who have the same ICD-10 diagnosis: primary open-angle glaucoma, bilateral, moderate stage, H40.1132.Optometrist #1, Dr. Smith, is not familiar with either the AOA or AAO guidelines or practice patterns, and has incorporated a lot of new technology into his practice within the last few years. He has visual evoked potential (VEP), electroretinography (ERG), optical coherence tomography (OCT), autofluorescence (AF) imaging and corneal hysteresis, in addition to fundus imaging and visual fields (VF). He sees this patient four to five times each year and performs VEP and ERG at least twice annually, OCT at least three times, AF once and corneal hysteresis once. He is able to manage the patient successfully and achieves a 15% drop in intraocular pressure (IOP) and maintains that IOP level.
In contrast, optometrist #2, Dr. Jones, is familiar with the guidelines and is more effective and efficient in delivering care. She also has purchased much of the same technology as Dr. Smith, but employs it only when the clinical evidence demonstrates the need for it. She sees her patient every six months and performs one VF and one OCT. She also achieves a 15% drop in IOP and maintains that IOP level.
Which physician is going to be attractive to health insurance carriers? You may think Dr. Smith is doing a better job by covering all of the bases, but this testing—translated into coding patterns when combined with H40.1132—would suggest just the opposite. He is less effective and efficient in getting the same outcome as Dr. Jones. Most likely, he will not be as attractive to carriers and may be dropped from the panel, paid less by the carrier or not even asked to participate at all.
This is the reality and potential impact of outcome-based care. Insurance carriers will grade each physician and it’s entirely plausible that practitioners in the same practice may have different patient groups for whom they are able to provide care.
Caring for patients with chronic conditions is a cornerstone of optometric practice. We must practice at the highest level while simultaneously evaluating our effectiveness and efficiency. Diligence is crucial to maintaining our position as primary eye care providers.
Send questions and comments to rocodingconnection@gmail.com.
| 1. Actis AG, Rolle T. Ocular surface alterations and topical antiglaucomatous therapy: a review. Open Ophthalmol J. 2014;8:67-72. 2. American Optometric Association. AOA Optometric Clinical Practice Guidelines. www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y. Accessed March 9, 2017. 3. American Academy of Ophthalmology. Guidelines. www.aao.org/guidelines-browse?filter=preferredpracticepatternsguideline. Accessed March 9, 2017. |
