Serving the Changing Visual Needs of Women Patients

Providing eyecare that serves the needs of women who are pregnant or experiencing other hormonal changes meets a vital need and projects a family-friendly message.

Women sometimes have eyecare challenges that differ from men due to the hormonal changes that they experience during pregnancy and at other times in their life such as through the use of contraceptive pills and during menopause. High-quality artificial tears and switching to a new silicone hydrogel daily replacement lens will become important to prevent excessive inflammation or irritation.

Many of your patients will experience similar symptoms due to hormonal changes. Here are some key points to consider about keeping women’s eyes comfortable through hormonal changes including pregnancy.

In Exam Room: Educate and Reassure Patient

In order not to assume anything, do not address pregnancy eyecare concerns until a woman has told me she is pregnant or asks about it on her own before then. Reassure the patient that pregnancy usually doesn’t cause major issues with eye health, but for those issues you do see, it usually has to do with contact lens intolerance due to hormonal changes in the tears and ocular tissues (most likely) or minor prescription changes that may or may not be permanent. The biggest concern is the development of gestational diabetes and potential diabetic retinopathy.

It’s good to let them know, however, that breastfeeding may extend the issues, but regardless, the benefits for the baby’s eye development through breast milk are fantastic! There are significant brain development advantages to breast milk. It is common for baby formulas to advertise that their brand offers all the necessary nutrients for eye and brain development. Breast milk is even better than those formulas as it naturally contains all of those nutrients. Since 30 percent of our overall brain function is dedicated to vision, the same nutrients in breast milk that enhance brain function also, therefore, are beneficial to the infant’s vision.

Added Precautions Recommended for Pregnant Patients

Don’t dilate pregnant or nursing women unless there is a prominent need to do so to adequately check the health of the eye (for instance, diabetes, risk of retinal detachment, or any other sight-threatening condition). In those cases, have them use punctal occlusion to limit systemic absorption. Rarely, you would come across situations of red eye/infections.

Conceptive Pills Also Cause Hormonal Changes

Even before women become pregnant, they may be experiencing eye discomfort related to the kind of birth control pills they are taking. If a woman has a sudden change in experiencing dry eye, or notices a pattern of dryness throughout the month, that is a flag to ask questions about what type of birth control she is on (it seems to be better with monocyclic brands than tricyclic because the monocyclic pills provide a steady dose of hormones whereas the tricyclic pills change hormone levels weekly and can be more problematic for SOME women).

Opportunity to Begin Education About Pediatric Eyecare

Become active in the InfantSEE program. Tell your pregnant patients about the program as a “gift to them and their baby” as the comprehensive exam is complimentary. As long as the baby is developing normally, they should have an eye exam in the first six to 12 months, again between ages 3-4, and every year thereafter. If there is a problem, there will be more exams scheduled. You should have a bulletin board in your office dedicated to taking pictures with the infants and then posting them up (with parents’ permission). It’s a great conversation piece and helps to educate others about the program.

Make sure you have the HIPAA Marketing Release Form signed before using marketing materials featuring patients.

Perennial Allergy Relief: A Practice Builder

Spring brings seasonal allergies, but it also is important to provide eyecare for patients with perennial allergies unrelated to seasonal changes. You will be rewarded with loyal patients who let others know of your services.

Allergies related to the change of season in the spring and fall is so common that many think exclusively of it when the topic of ocular allergies comes up. Providing for seasonal allergy patients is essential, but don’t overlook another segment of allergy suffers–those with allergies unrelated to these common factors. Here are key points to keep in mind to serve patients with allergies that don’t go away with the passing of spring or fall.

May Be a Systemic Reason for Allergies

Most nonseasonal, ocular allergies are associated with dust or dust mites, animal dander or mold. Another chronic ocular allergy called vernal conjunctivitis worsens in warm weather, but is not due to typical seasonal triggers such as pollens. Instead it is an IgE mediated mechanism found in some patients who also have a family history of other atopic diseases such as asthma, eczema or hay fever. GPC (giant papillary conjunctivitis) may also result as a form of ocular allergy to long-term buildup of deposits on contact lenses worn for a prolonged period of time. Acute reaction to some forms of cosmetics is also not uncommon.

Bill Medical, Rather than Vision, Insurance

The amount of reimbursement varies from one insurance company to the next, but you would generally receive approximately $90 to $110 for the initial visit and $39 to $65 for each follow-up visit. You should typically see the patients an average of three times to diagnose, begin treatment and follow up until their symptoms are resolved and they are stable, and then again several months later to make sure they are still OK.

A Potentially Significant Group of Patients

The more severe cases are chronic allergies. Chronic allergies often can be inherited and/or the patient has a history of hay fever, asthma or eczema. Patients are typically younger–early 20s or younger. It is more common in males than females. Many of these cases are children. Practicing in the tropics also had an impact with warm weather often worsening the symptoms. Long-time contact lens wearers who wore extended wear lenses without frequent replacement, who then developed GPC, also were common. Middle-age females would account for most of the cosmetic reactions leading to allergies.

Know the Signs of Non-Seasonal Allergies

Most of the time these patients would come in complaining of discomfort and show clinical signs such as moderate to severe injection, minimal to moderate lid edema or just heaviness of their eyelids. Other common signs of  this form of allergies include mucus discharge, itching and/or burning eyes. At times these patients also would experience concurrent rhinitis. Other times they would complain of contact lens intolerance and come in wanting a new contact lens prescription thinking that is what they need.

Prepare to Treat Non-Seasonal Allergies

There is no special equipment beyond the typical instrumentation needed to diagnose this form of ocular allergy. Most of the examination can be done directly and with the aid of a slit lamp. Corneal dyes are often used to aid in the examination.

Understanding the pathology and clinical picture of these conditions and the differential diagnoses is important. Along with taking advantage of ocular allergy learning opportunities at conferences, keeping up with the related medical literature is also extremely helpful.

Educate Your Patient

Helping the patient understand what is happening to their eyes and explaining both the realistic short- and long-term expectations are what most patients want, in addition to the most rapid relief possible. This will provide the patient piece of mind. If there is something the patient can do to improve their situation and prevent issues in the future, such as more frequent replacement of contact lenses (like daily replacement), then explain why this change is necessary and how a change in their contact lens routine may lead to greater comfort.

How Do You Price Free Form Progressive Lenses?

Freeform progressives are commanding top dollar at many optometric practices, according to The Vision Council November 2012 Eye Care Professional Report. The most expensive progressive lenses being dispensed were free form progressives which sold on average for $413.14. Free form progressives were less expensive at smaller practices. Practices with only one location sold free form progressives for an average of $402.93, while practices with more than five locations sold free forms for $436.82 on average–over $30 more per pair. Free forms were also more expensive in the Midwest region of the US than other regions ($431.60 in the Midwest vs. $382.39 in the Mountain-Pacific region.

 

How freeform progressive lenses are doing in your practice?

If you have an average practice, you are seeing 2,200 patients for exams with refractions per year per doctor. Approximately 60 percent are getting eyeglasses–that would be 1,320 people (eg: .6 x 2,200 = 1,320). Of the 1,320 people who get glasses, approximately 50 percent are single vision and 50 percent are multifocals. That means 660 potential pairs of freeform progressive lenses per year could be sold in your practice.

Vision Impact Institute

Essilor, an international producer of ophthalmic optics, launched an organization dedicated to socio-economic-related vision issues: the Vision Impact Institute. Today’s most widespread disability, impaired vision, affects 4.2 billion people throughout the world, of whom 2.5 billion have no access to corrective measures.

In its quest to achieve better vision for all, the Vision Impact Institute will act as a global connector of knowledge, data and solutions. The Institute’s mission is to raise awareness about the socio-economic impact of poor vision and to foster research where needed, encouraging measures in the field of corrective vision. It will work to ensure that poor vision and the economic implications emerge as a global challenge.
This public health issue has substantial economic consequences at both an individual and collective level: $269 billion in productivity is reportedly lost every year because of impaired vision, even though all the required solutions (eye exams, corrections) are available.

The underestimated economic impact of impaired vision

While one of the most widespread disabilities in the world, impaired vision and its cost are still underestimated in developed and emerging countries: 30 percent of young people in the world under the age of 18 reportedly suffer from uncorrected refractive error, which is often not diagnosed due to lack of awareness or access to care. This proportion rises to 33 percent in the labor force, 37 percent among elderly people and 23 percent among motorists.

The economic impact is significant globally: around $269 billion in productivity is reportedly lost every year, including $50 billion in Europe, $7 billion in Japan, and $22 billion in the United States–even though there are solutions to correct most of these impaired vision cases.
The annual global cost of productivity loss corresponds to providing an eye exam for half of the current world population. Thus, simple measures might drastically reduce the economic consequences of impaired vision and also the social ones, even though the cost, level o f access to care, and awareness differs by country.

Post-LASIK Education: Let Patients Know They Still Need You

Providing ongoing care for post-LASIK patients keeps them in your practice and ensures that they receive the services and products they need.

LASIK has become a common procedure improving the lives of many of those who undergo it, but many of those same patients don’t realize that they still need to visit their eye doctor annually. In addition to co-managing pre- and post-operative care for LASIK patients, ODs need to educate these patients about why they still need to visit for a comprehensive exam each year. Education also is needed about which products, such as sunwear, are still beneficial, and why a successful LASIK procedure doesn’t mean a patient won’t need to address presbyopia.

Vision and Eye Health Could Change

Although patients can now see well, they need to be examined on an annual basis. For those getting close to presbyopia, they may need reading glasses in the near future and need to continue monitoring their eye health for such issues as glaucoma, cataracts and macular degeneration. Other LASIK patients are very non-compliant and literally disappear after their surgeries, either showing up rarely or never again.

Monitor and Treat LASIK-Related Dry Eye

Many LASIK patients are people who have had dryness issues that affected their ability to wear contact lenses and require treatment methods for anyone who has dryness including lubricants, Omega 3 supplements and punctal plugs when necessary.

Educate On Added Need for Sunwear and Driving Eyewear

LASIK patients are more prone to glare problems after surgery, especially at night. Many patients have LASIK with a monovision modality, so their eyes are unbalanced for distance vision and these patients can often benefit from night driving eyeglasses, as well, that balance both eyes to distance.

Monitor Eye Health Long-Term

Continue to monitor post-LASIK patients for the same medical eyecare problems that can affect anyone such as glaucoma and cataracts. Also monitor the cornea for any signs of a condition called ectasia, which is an abnormal thinning and bulging of the cornea. Since the surgery leaves the cornea thinner, this can happen, although it is uncommon.

Anticipate the Rare Poor LASIK Outcome

In most of these cases, the problems were not medical, but a result of a patient with unrealistic expectations. Some patients who had the oldest refractive surgery, radial keratotomy (RK) have had massive shifts in their refraction over the years, ending up extremely hyperopic. In addition, their best corrected visual acuity is often not correctable easily to 20/20 vision.

Generate Post-LASIK Patient Referral

Ask for referrals of the patient’s friends, family and co-workers who may be interested in LASIK surgery. Often, the patient’s happiness and enthusiasm is highest right after the surgery, so this is a good time to ask for referrals. The referred patients will not necessarily be excellent candidates for surgery, but will then continue coming to our office for their eyeglasses and contact lens needs.

How Satisfied Are Patients With Exams at Independent OD vs. Chains?

Independent ODs are leaving a more favorable impression with patients than corporate-owned optometry chains, according to Jobson Optical Research’s 2012 Adult Consumer Eye Exam Experience. Fewer consumers who had an exam at a chain in the last six months strongly agreed with the statement that overall they were satisfied with the eye exam experience compared to those who had an exam at an independent in the last six months (45.3% and 58.1% respectfully). Indeed, just under half of those consumers who had an eye exam at a chain in the last six months (46%) said the exam was thorough, compared to 58.9% of those consumers who had an eye exam at an independent in the last six months.

Among consumers who had their eye exam at a chain in the last six months, 53.4% said they were extremely likely to return to the same place for their next eye exam. By comparison, 70.7% of those who had their eye exam at an independent in the last six months said they were extremely likely to return to the same place for their next exam.

Of the respondents who had their exam at an independent in the last six months, 63.5% reported that they are currently covered by a type of managed vision care or vision insurance plan. This is greater than the 53.9% who have a vision plan and chose to have their eye exam at a chain in the last six months.

How Many of Your Patients Know What Digital Eye Fatigue Is?

You have some digital eye fatigue syndrome education to deliver to patients. 72% of patients are not even familiar with the term “digital eye fatigue,” according to The Vision Council’s VisionWatch Digital Eye Fatigue Syndrome report. Those patients with children will also need an education on the impact of the condition on their children’s eyes, as 37% of patients with children say they are not concerned about it. Interest in digital eye fatigue syndrome in children, however, may be growing. 47% say they are somewhat concerned about the condition affecting their children and 16% say they are very concerned.

1)  Review your verbal communication to patients. Record and listen to your case presentation. Make sure you are not talking over the heads of your patients. The more complex your sentences and the more syllables in your words, the less likely patients are to understand what you are trying to communicate. 2) Review all written communications from your practice to patients. Check your web site, your treatment protocol handouts, your recall communications; make sure everything is built to communicate in a clear an effective manner. Simplify.

Now, does it really surprise you that 72% of patients are not familiar with the term “digital eye fatigue syndrome?”  Wouldn’t this be better communicated to patients as: “Do your eyes get tired when you spend time reading on your tablet or phone?”

Who Does Better Financially? Solo ODs or ODs in Partnerships?

Optometrists who practice alone are up against greater financial odds than those in partnerships. Annual income for solo doctors averaged $144,125 last year. But ODs in partnership or group practices averaged $191,195—a difference of nearly 33%. Like other doctors, the report surmises, optometrists are under an ever-growing pressure to invest more in technological and practice costs; group practices can share these expenses and take advantage of efficiencies of scale. That can translate to more profit.

Net is an interesting topic in the optometry world. There are actually two different “nets” we should discuss.

The Optometric Net is calculated by adding together all dollars paid to all optometrists (both employed optometrists and owner optometrists) for working in the practice plus any money left over after paying all other expenses. This is the number that is traditionally referred to as the “Net” in optometry. This practice is unique to optometrists.

A True Net is calculated by subtracting all expenses including what it costs to have optometrists in the practice from all money collected. This is the number that all other businesses in the world (except optometric practices) use to judge fiscal health.

Formula:                  

Money collected-Cost of Goods-Payroll-Occupancy-Marketing-Overhead=Optometric Net-Optometric Payroll=True Net

You need to know both numbers, the Optometric Net and the True Net. There are a two major reasons: tax consequences and future consequences.

It matters, from a tax perspective, how you remove income from a practice. This is a discussion you should have with your tax planner as soon as possible. It is your responsibility to pay any taxes that are appropriate, but if you have not had the discussion of how best to remove money from the practice with your tax planner, then that conversation needs to be scheduled now.

As the owner of the practice, how do you know how much you are going to be paid?  If you are just waiting to see how much money is left over and that becomes your “payroll” amount, then you are not treating your practice as a business. Hiring an optometrist to work in your practice is a business expense. If you are working in the practice, then you need to be hired by the practice to do that work. Every business needs to know its true expenses. You need to know yours.

Do Your Patients Know About their Sports Eye Injury Risk?

Every 13 minutes, an emergency room in the United States treats someone for a sports-related eye injury. According to the National Eye Institute, eye injuries are the leading cause of blindness in children in America, and most injuries occurring in school-aged children are sports-related. The results of an eye injury can range from temporary to permanent vision loss.

The NEI notes that baseball is the sport responsible for the greatest number of eye injuries in children aged 14 and younger. While basketball is the sport that records the highest number of eye injuries for those ages 15-24.

Polycarbonate lenses must be used with protectors that meet or exceed the requirements of the American Society for Testing and Materials (ASTM). Each sport has a specific ASTM code. Polycarbonate eyewear is 10 times more impact resistant than other plastics.

Eye injuries can include painful corneal abrasions, blunt trauma and penetrating injuries, inflamed iris, fracture of the eye socket, swollen or detached retinas, traumatic cataract and blood spilling into the eye’s anterior chamber. All athletes who have poor vision or blindness in one eye should take particular care to protect their remaining vision.

Code Correctly for External Ocular Infections

 

Treating external ocular infections is a practice builder. Coding correctly and processing billing efficiently makes it profitable.

Conjunctivitis, keratitis and blepharitis are treated every day in most busy optometric practices. Knowing how to properly code and bill for these conditions is extremely important if you want to avoid getting behind on your daily schedule of patients. Not knowing correct coding takes additional time to figure it out , and sometimes leads to staffers just throwing their hands up in frustration and not coding at all. For example, consider how easy it is to make the following mistake if your office does not know proper coding for ocular infections:

Correct coding:
Initial office visit for a new patient 99203 or 99204 and follow up visit one day/one week later 99213/92012 with follow up one week/one month later 99212/92012.

Incorrect coding:
Initial office visit for a new patient 99203 or 99204 and follow up visit one day/one week later 99214/92014 with follow up one week/one month later 99214/92014.

Proper Coding Makes Treatment of Ocular Infections a Practice-Builder

Treatment of most external ocular disease is well within the therapeutic level of licensure for all optometrists and is an excellent way to build your practice volume. Treating these conditions ensures that your patients will come to you first whenever they have a red or painful eye. If you properly treat their ocular condition, patients will keep coming back. Lid disease such as blepharitis/meibomianitis can grow your practice significantly.

An abundance of ICD-9 diagnosis codes are available for coding ocular infections due to the multitude of different eye infections that we are able to diagnose and treat. The following is a short list of the more common diagnoses:
LACRIMAL SYSTEM
375.01 Acute Dacryoadenitis
375.02 Chronis Dacryoadenitis
375.32 Acute Dacryocystitis
375.42 Chronic Dacryocystitis
CONJUNCTIVA
053.21 Herpes Zoster Keratoconjunctivitis
077.1 Epidemic Keratoconjunctivitis
077.3 Adenoviral Conjunctivitis
372.20 Blepharoconjunctivitis, unspecified
372.30 Conjunctivitis, unspecified
CORNEA
053.21 Herpes Zoster Keratoconjunctivitis
054.43 Herpes Simplex Keratitis
370.01 Marginal Corneal Ulcer
370.03 Central Corneal Ulcer
370.21 Punctate Keratitis
370.40 Keratoconjunctivitis, unspecified
SCLERA
379.01 Episcleritis Periodica Fugax
379.03 Anterior Scleritis
EYELIDS
372.00 Blepharitis, unspecified
373.11 External Hordeolum
373.12 Internal Hordeolum

CPT codes most frequently used for external ocular infections mainly consist of office visits coded with 99201-99215 or 92002-92014. Additional testing may include 92285 External Ocular Photography and 87809-QW Adenovirus Detection. Note that to use this code, you must have an adenovirus detector and a CLIA waiver from the government. External ocular photography is used to document the disease and educate the patient on treatment success. Adenovirus detection performed in the office using the RPS adeno detector determines whether the infection is caused by an adeno virus as opposed to a bacterial infection. Knowing the cause of the infection makes choosing the correct treatment plan easier.
Laboratory testing like the adeno detector requires a CLIA waiver if you want to be reimbursed by insurances. The CLIA waiver is obtained by submitting an application along with $150 and allows you to perform a limited number of laboratory tests in your office. Reimbursement is minimal and dependent on the insurance carrier.
Corneal edema is often associated with various forms of keratitis and has a list of ICD-9 codes including the following:
371.20 Corneal Edema, unspecified
371.22 Secondary Corneal Edema
371.23 Bullous Keratopathy
371.24 Corneal Edema due to Contact Lens
CPT codes for additional procedures performed to treat corneal edema include:
68761 Lacrimal Punctal Plug
76514 Pachymetry
92025 Corneal Topography
92071 Bandage Contact Lens
92285 External Ocular Photography
92286 Specular Endothelial Microscopy
Reimbursement for these procedures is dependent on your insurance carrier and varies, so it is important to review your EOB (explanation of benefit) to determine which carriers reimburse and what the payment allowables are.