Q: I am a young, progressive optometrist with a large population of glaucoma patients. Do I need to comanage all of them if I dont have one of the latest imaging devices, such as a GDx, OCT or HRT?

A: You certainly dont need to comanage every patient. The best people to treat and manage glaucoma are optometrists, because glaucoma is usually a non-surgical condition that typically changes very slowly over time, says optometrist Eric E. Schmidt, president of Bladen Eye Center, a secondary-care practice in Elizabethtown, N.C.

Also, not every optometrist who sees glaucoma patients needs to buy an imaging device. Without a doubt, you can diagnose, treat and monitor glaucoma progression without an imaging instrument. I dont think that because you dont have one, you should not manage it, Dr. Schmidt says. The best, purest way to diagnose glaucoma is to look at the optic nerve head and its progression over time, and an imaging device will never replace your eyes and your 78D lens.

Glaucoma is, first and foremost, a disease of the optic nerve, he says. Look at the optic nerve head, and make your diagnosis of glaucoma based on the optic nerve heads appearance. All the other testsvisual fields and imagingare great, but they are ancillary to the tried and true disc evaluation, Dr. Schmidt says.

Glaucoma is, first and foremost, a disease of the optic nerve.

That said, most doctors who see glaucoma patients (especially those with a large glaucoma population) should at least have the ability to obtain a patients optic nerve or nerve fiber layer image, if needed.

An audience poll of 629 optometrists at SECO International showed that 38% had a nerve fiber/optic nerve analyzer in their office. Thats not to say that every doctor should run out and get an instrument, Dr. Schmidt says. But I do think that all eye doctors, ophthalmologists included, who do manage glaucoma patients should have that technology available to their patients.

Dr. Schmidt suggests at least two ways to obtain images without buying the instrument or referring the patient to another doctors care:

Schedule a visit from a mobile instrument company. Several businesses are willing to come to your office with a mobile imaging instrument once a month or so and perform scans on your patients. The company charges you for each scan and you submit the tests for reimbursement.

Strike an agreement with another doctor. Call the eye doctor down the street, even if hes a competing O.D., and begin a relationship where you send your patients for the scanand only the scan. It can be performed by the technician. The patient comes back to you for analysis of the test. Thats a win-win situation for you, the patient as well as the other doctor, Dr. Schmidt says. The doctor with the instrument can bill for the test. You can bill for the analysis of the test. And, most importantly, your patient gets the test he needs.

Q: What if I just saw a patient two months ago? Id like to check his condition again, but can I bill for another visit?

A: Certainly, yes, Dr. Schmidt says. By and large, most insurance plans will permit this if you document why a glaucoma patient warrants another visit.

However, Medicare guidelines allow only one retinal scan per year. But in cases where progression is documented or where there is documented medical necessity to perform another one, it can be successfully performed and billed, although you may need to obtain prior approval or to secure an appeal, he says.

Vol. No: 142:7Issue: 7/15/2005