Meet the Growing Challenge: Treating Macular Degeneration

Our aging population is providing more cases of macular degeneration. Serve this growing need by discussing UV protection and lifestyle changes, and by providing early detection and early treatment. Technology is advancing; educate yourself on improved detection and treatment options.

With the Baby Boomer generation (those between 1946-1964) aging into senior citizens, macular degeneration is increasingly being diagnosed.  Taking steps to prevent and treat macular degeneration is the right thing to do, but it also is a great practice builder as you are providing services vital to the health of your community.

Institute Screening for all Patients

Patients who have a family history of macular degeneration are the most susceptible to this disease, but with the occurrence of it so common today, you should screen all patients. Take a baseline digital retinal photo and then review the image with patients letting them know if and where you see potential for disease inside their eyes. Point out details such as their optic nerve, the blood vessels and macula. Create a policy to photograph the retina at each annual exam (similar to a dentist requiring an x-ray annually), and, more frequently if they have diabetic or hypertensive retinopathy, AMD or a retinal hole, tear or degeneration that should be monitored more frequently. That way, everyone is screened and that creates an ideal opportunity to discuss prevention of potentially blinding eye diseases, like AMD and glaucoma with annual eye examinations, good nutrition and protecting the retina from UV damage. You can charge for the photo taken and advise the patient there will be a charge. You can participate with Medicare and Horizon BCBS for medically based eyecare. The billing code is 92250 and the diagnosis would be 362.57 (drusen) or 362.51 (dry AMD).

You shoulde explain the effect that ultra violet radiation has on this part of the eye and why it is important for patients to protect their eyes from the sun with quality sunwear.

Educate Nutrition and Personal Habits

In addition to explaining the importance of sun protection, you can point out how smoking triples the risk of developing AMD.  Explain the importance diet plays in prevention. For instance, according to the Mayo Clinic, eating kale, spinach, broccoli, peas and other vegetables, which have high levels of antioxidants, including lutein and zeaxanthin, may also reduce the risk of macular degeneration.

Talk Supplements

In addition to protecting eyes through the use of quality sunwear, a better diet and avoiding smoking, you should recommend that all patients, and especially those who are 50 and over, or those with a family history of macular degeneration, take MacuHealth, a macular degeneration-focused nutraceutical. The script has a toll-free number patients can call; it is $75 for a 90-day supply. Macuhealth is only available through a Doctor of Optometry or Ophthalmology or by dialing the toll-free number on the Rx pad. It is NOT available in drugstores or on other web sites.

Educate that in an Era of Electronic Screens, All Are At Risk

More research needs to be conducted in this area, but evidence is beginning to emerge that the blue light emitted from electronic devices like laptops and mobile devices, along with the light emitted from compact fluorescent (CFL) lightbulbs, increases macular degeneration risk. This is one more reason to take precautions regardless of your age or family history. Explaining the possible role these modern forms of light play in increasing macular degeneration risk, you can also emphasize the importance of annual comprehensive examinations in protecting eye health.

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Vitamins E, C No Help Against Macular Degeneration

Taking vitamins E and C may do nothing to protect aging eyes from macular degeneration, in the longest-running one to test vitamin E for eyesight in men, and the first to test vitamin C alone.

According to researchers of Brigham and Women’s Hospital and Harvard Medical School in Boston, the findings offer no evidence to support taking vitamins E and C to ward off vision problems. The report published in Ophthalmology, is part of an ongoing study of more than 14,000 U.S male doctors age 50 and older. The men were either taking both vitamins, only one of them, or neither.

After 8 years, 193 men had developed macular degeneration that was serious enough to interfere with their vision, but the risk was nearly identical among vitamin and placebo users.

Revenue Annuity: Treating Macular Degeneration

For low upfront costs, you can add comprehensive macular degeneration care to your practice services and tap an immediate revenue stream. There is an often-overlooked opportunity in managing macular degeneration patients. Theirs is a treatable condition, not a curable one, so long-term treatment is built in. These patients require close follow up and are typically very loyal and compliant as they seem to understand the serious nature of this disease and the risk that accompanies this condition. They will also refer their family members to your practice since they are aware of a possible hereditary component.

High Volume Dependent on Practice Demographics

The number of macular degeneration patients depends on the demographics of the practice. An older Caucasian population will have a higher percentage of macular degeneration. Regardless of the number of patients you have with macular degeneration, it is an opportunity to build a personal relationship with those patients and their families. You can raise your credibility by being knowledgeable about such a serious eye condition, and that brings referrals. Even patients without macular degeneration will have a great degree of trust that you will be able to detect a serious problem since you are experienced in caring for macular degeneration patients.

Number of Follow-Up Visits Depends on Disease Stage

The number of visits-per-year depends on the stage of the disease. A patient with very early macular degeneration may only need to be seen twice a year. However, you can bill at a higher level and perform other testing for which you will be reimbursed. Retinal photography and OCT are examples of additional testing that may be necessary for these patients. In the more advanced stages, or the wet form of the disease, there are more office visits involved and potentially co-management with a retinal specialist. The codes used are the same codes for the appropriate level of the office visit and the actual testing or procedure you perform.

Consider Offering Low Vision Aids

In cases where the disease is in the more advanced stages, and has resulted in significant visual loss, there is an additional opportunity for low vision exams and selling low vision devices. There is a great opportunity here since most ODs and retina specialists do not offer this type of service. However, it does take commitment and patience to offer low vision aids. It is a highly specialized service and takes more time than a typical exam.

Billing and Coding for Macular Degeneration

Regular office visit codes for the appropriate level are used as well as special testing codes. The use of special testing codes may trigger an audit so it is very important to be familiar with local rules and guidelines and to document extensively in your medical records. However, done appropriately, using the following codes can bring a boost to your practice.

92134: Scanning computerized ophthalmic diagnostic imaging of the retina with interpretation and report, unilateral or bilateral. This is a fairly new code billed once whether you scan one eye or both.
2019F: dilated macular exam
4177F: AMD counseling with AREDS supplements
92250: Retinal photos. Frequency is determined by what is medically necessary. This usually will be covered as a baseline and to monitor change but not simply to document the existence of the condition. Practitioners should check with the carrier guidelines as to how this is covered.
92082: this is the code for visual field that may be used for preferential hyperacuity perimetry with the Foresee PHP. This may or may not be covered.

Invest in Necessary Instrumentation

Typical instrumentation found in any optometric practice such as a slit lamp and binocular indirect ophthalmoscope with retinal lenses are used. Additional macular lenses are highly recommended. These are not expensive, typically running a couple hundred dollars. Depending on the volume of patients you have, it may be advantageous to invest in retinal photography and a retinal scanning laser. This type of instrumentation is quite costly–in the thousands to tens of thousands of dollars–but can be leased, as well. There are other alternatives to investing in your own instrumentation. There are companies that will bring the diagnostic instrumentation to your office for a few hours or a full day. They charge a fee, so you would schedule numerous patients to come in on the same day. Depending on your needs, this can be done once a week or once a month, etc. Although not as convenient, you also can refer macular degeneration patients to a local OD who does have this instrumentation and have them perform the technical portion and get the patient back to you. This will require a good relationship with that practitioner and their office staff.

No Certification Required

There is no additional certification needed, however, a thorough knowledge and comfort level with the disease process, risk factors and currently available treatments and anticipated outcomes are required to manage these patients. A good working/co-management relationship with a retinal specialist who treats macular degeneration is also necessary. The patient will ultimately rely on you, the primary OD, for appropriate referral and a thorough explanation of their options and expectations when being referred to the retinal specialist. You should understand the retinal specialist’s preferred method of treatment and general protocol and have regular and open communication with the specialist. Often the patient will return to the referring OD asking for an explanation of what happened in the retina specialist’s office. These patients are usually well aware of the serious nature of this disease and are afraid of going blind. You must be well informed and able to educate them.