 So it gives me special pleasure to introduce our next speaker. Dr. Terry Spencer was not only a resident here at Moran Eye Center, but he was also a pre-residency fellow at my laboratory. So we're very excited to have him come down and speak as one of our clinical faculty members. He now has a very busy private practice at the Black Hills Center there in Rapid City, South Dakota. And he's going to talk to us a little bit about co-managing cataract surgery patients. Dr. Spencer? Well, I'm very grateful to be back here where I trained actually not in this building, but in the old Moran building. It's really great to see old friends and people who are helpful and responsible for me having a fun and successful career. So it's nice to be able to come back and try and give some information back. And this is the information that I never got as a resident, because there's really no residency you don't get involved in billing, and certainly not in co-managing. It's really not a thing that's necessary here, but where I am it is. So when I told Nick I could give this talk back in like February or March, so it was still clinical faculty day. I don't have any research to translate for you, so sorry about that. I'm not paid, I don't have any interest, and I'm not going to talk about anything that has anything to do with any companies in specific. And this lecture is not intended to support expanding optometry scope of practice. It's really not a problem in South Dakota. I do have a child who is an undergraduate here on campus, a sophomore. So that's a financial disclosure. Yes, that is it. So I'm right off this trip to come out here and see my son and give a lecture. But it is true we get out there in private practices and away from academic centers that optometrists and ophthalmologists do have to work together. And I'll show you why in a moment. But co-management is a relationship where the surgeon can do the case and the patient's regular eye doctor can see them and take care of their follow-up care. The surgeon is ultimately responsible for anybody that has a surgery. But they can share care and follow. That's different than a transfer of care, which is when a different circumstance, say somebody's referred over to another person, you no longer have responsibility. In co-managing, the surgeon does have responsibility. And there are a lot of optometrists that are out there that want to co-manage their patients. There's different reasons and there's even some controversy about that in the medical world. But there are situations where it is totally appropriate for cataract surgery patients. So what I wanted to do is tell you how you do it, what is ethical, what are the rules and how to bill for it. So I live in the Black Hills, which is this little hilly mountainous area in the middle of a great big area of plains. And this little symbol represents there in our town in Rapid City. We have ophthalmologists and optometrists. And the next closest ophthalmologists are like 250 miles in any direction. So there is a lot of space out there where they're just optometrists. It's a little different than the setting you guys have right here in this valley. But what happens when a patient in Eagle Butte needs cataract surgery or a patient in the middle of nowhere that these people literally drive a couple of hours just for their appointments. So this is an indication where co-managing is a situation that can be helpful and it's in the patient's best interest. They don't want to come to Black Hills anyway because it's so beautiful. This is a picture I took in the Black Hills 25 miles from my house where you can drive through tunnels and look right up Mount Rushmore. And so Rapid City has 11 ophthalmologists and it's only a population of 70,000 but they're all way more busy than what you would expect. Normally I think they save 20,000 population for each ophthalmologist. So let's talk a little bit about the co-managing. In my practice the patients have been going to their optometrists for all their routine care for a long time and then those are the ones who typically diagnose them. I don't have a practice full of people who come to me for routine care. I don't even do... My practice is so busy with medical and surgical problems I don't even do contact in glasses. It's not part of what you have to be efficient and so we have to divide and conquer these tests. So the optometrist is deciding when that rancher needs to come in and have their surgery. And the treatment for their cataract initially might be observation or it might be some guy comes in off the farm, hasn't seen a doctor for 10 years. Whatever the situation might be, but they decide when a cataract is advanced enough to refer. It's the ophthalmologist who makes the decision for surgery. So when a patient is referred it's for an evaluation. And that comes from the recently updated Asper's position paper that the ophthalmologist is responsible for all surgical care including post-op care. And that starts with the determination of the need for surgery. So I'll show you a sample of what I'm talking about here. A woman might be referred by her optometrist for cataracts. She comes in with... You see the referral note, maybe 2 plus nuclear sclerosis. Vision might be not 2020. And she complains that my vision gets blurry after reading for a while. Otherwise I see just fine. And so in this case, it might not be that you need to treat what she was referred for. You know, during your normal evaluations you're going to find out what their complaints are, what are their effects on their daily visual activities. But in someone like that, you know, that cataracts don't cause vision to fluctuate in the way that the dry eyes do. And you saw from that little picture that she had dry eye syndrome. So here's a patient that was referred for a cataract surgery that ends up being treated for dry eyes. And in a situation like that, you might recommend some treatments, maybe send a letter back. You might... Some optometrists like to do plugs or put people on meds. Sometimes you end up doing that. You might follow up on the patient or have the optometrist see them back. Not every patient that is referred for cataract can or does necessarily need cataract surgery. And so I have had many patients that get sent back. And, you know, what we do is we give lectures to the optometrists once a year so they kind of know... When you work with the optometrists routinely, you know which ones kind of know what to do and you can teach them. And so they don't take it personally. But when you have a patient like that, it's easier to... Sabs have everyone happy in the long run when you treat them right and when they have real cataract complaints. There's another picture in the Black Hills. I always thought this was cool. They have this highway where there's these little pigtails that they kind of wrap around in order to get up the hills. Last month, they had, you know, the usual Sturgis rally where there's, like, 500,000 people on their Harleys that come to right there. Fun place to come in August if you want to... if you like people watching. So when is surgical treatment indicated? I adapted this talk from a talk that I give to optometrists. But most of the medical stuff has been taken out of this talk except I left this slide in. Just because you should know when cataract surgery is indicated and it's based on visual function or lens-induced diseases like fakeomorphic glaucoma, or it's necessary to visualize the fungus in an eye that otherwise still has visual potential. But my optometrist thinks I need a multifocal IOL is not an indication for surgery. If patients can see well with their glasses or contacts and their activities of daily living are not affected then they don't necessarily need surgery. If surgery won't improve visual function, the asperess there is because there are some other situations like the fakeomorphic glaucoma type stuff. If they can't undergo surgery because of coexisting medical conditions and if appropriate post-operative care can't be obtained. So if there are patients who say, you know what, I'm going to be out in the middle of nowhere on my ranch and I'm not going to come in for follow-ups, they don't get surgery. Some Medicare carriers require more specific when it comes to reduced visual acuity and such. So we have to follow those guidelines as well. And inducement for surgical referrals coercion by referring practitioner are not factors that should influence your decision to do cataract surgery. You know, the optometrist who wants to go out and find which doctor is going to pay him the most money, the surgeons who want to give gifts or kickbacks, that's not allowable. That's not why co-managing is done. When the optometrist refers a patient, they need to inform that patient that the ophthalmologist is going to see them in clinic. So many people come in and think, okay, I'm having my surgery today, right? And it's like, no, sorry, you're not having it today. And they might discuss options. Optometrists might know that a patient has used multifocal contact lenses, for example, or they have used contact lenses for mono vision. And when they refer patients, that's the kind of information that needs to be communicated back and forth. The options for expensive premium lenses or upgrades should not be a factor on who they refer patients to. Optometrists know the patient. So when an OD sends me a referral note and says, call me and I call him up and he says, man, this is the guy who is the engineer type that is always complaining. He comes back every year. He comes back, his glasses aren't right. This guy you can never please, never make happy. That's another important piece of information because that might help you decide if this patient is a candidate for something like an upgrade option. The ophthalmologist in a co-managing situation is responsible for the consent, the plan, the options, the expectations, and to inform the patient or discuss the options for co-managing on postoperative care arrangements. Co-management cannot be done as a matter of routine policy on all patients. It's unethical to share the care for economic reasons. Patients have to consent. They have to sign a form that says that they understand what the arrangement is and that they have access back to the surgeon if needed. And there's no fixed time. You can't have a policy that says I always am going to see the one-day follow-up and my optometrist is always going to see the one-week follow-up. You have to wait and see what the patients look like and make sure that they're in a stable condition to go back. The patient has to have access to the surgeon. Now, when they're seeing somebody way off in the middle of nowhere and the optometrist is there, there can be situations where maybe they can't get back right away. If you've got a patient that's a far ways away and has some kind of postoperative problem, you really have to have a way to perhaps travel is arranged, things like that. I've seen cases where an optometrist tried to lower the eye pressure and instead of trying to make a little tap on that small paracentesis incision, they pushed on the big temporal clear corneal incision until the iris came out and then you got another surgery coming up. So you want to make sure you communicate and educate your optometrist in co-managing situations. And it should not be done against the patient's interest. It's not done because it helps the optometrist and it helps the ophthalmologist get more referrals from that optometrist. So let's talk about what that's worth. The value of the postoperative care is 20%. Now, that doesn't make sense. It's 20% of the global package which includes the surgery and the postoperative care. When you're talking about Medicare, if you're doing a cataract surgery and you're co-managing the surgery portion that you built for gets this modifier 54 and automatically the surgeon gets only 80% of that surgeon fee. And the 20% is shared between the ophthalmologist and the optometrist. If an optometrist sees all of the postop care, they would get that entire 20%. So here's an example case. Cataract surgery on May 1st, the surgeon builds with the modifier fee 54 for the surgery and Medicare gives them 80% of the total global fee. The rest of it is going to be divided up. So for the postoperative care, the surgeon who sees them will be billing that patient for a portion of that 20%. So if the optometrist takes over care on May 12th, which is 10 days after the surgery, they bill for 80 out of 90 of the days. And so that 20%, the optometrist will collect whatever percentage that is. You have to follow proper Medicare billing guidelines and use the appropriate codes, and I think most of the private insurances follow the same rules. And if your surgery code is upgraded to a complex surgery, you have to let the optometrist know because they have to build their co-managing postop under that same coding. Medicare requirements do not apply to the refractive or upgrade portions. So there's lots of different ways that this might be done. And to tell you the truth, I don't know what is lawful in this situation, but what we do is try to make it so if there's an upgrade cost on a patient, then the OD can actually get part of that cost. But it has to be at a fair market value. For example, if they're billing for a total of 10% of the follow-up care, then 10% of that upgrade fee might be something that seems as a fair market value as well. So when it comes to the premium lenses, I think optometrists are very helpful, like I was saying. They know the patient. They're happy to see them back. They're excited to see new technologies, but they should be familiar with the options and they should not get kickbacks. And like I said before, I think there are places where the surgeons kind of require or incentivize ODs with premium IOLs and that's not ethical. Communication is really important. You know, pick up the phone, call your optometrist you're working with. If it's somebody new or you haven't worked with them before, make sure you find out if they are comfortable with that. Have they done an optometry fellowship where they've seen post-operative care or have they been in a situation where they see a lot of that? If not, you might invite them to come and watch surgeries so they know exactly what's going on. I've had a lot of optometrists come into the operating room and watch cases with me. Make sure you send notes back and forth, especially if there's anything unusual. If a patient had a high follow-up intraocular pressure and you added an aqueous suppressant drop to their post-op regimen and they're in a situation where they're maybe following up next time with the optometrist, make sure they know what your plan is, what pressure expectations are and what to do with the drops. And that's it. Take any questions? A little bit different, but I thought you guys might enjoy seeing something that comes out from a private practice perspective. I do some research, too, but what I do is those kind of FDA trials where there's multi-center things and they need sites to do cases for a phase three approval. But sorry, again, nothing to translate. Brett? Terry, I think especially in a place like Rapid City where, like you said, access to care is so difficult for people to live in the sticks, this model is really effective. And I think the fact that you also combine the education piece by giving lectures for the optometrists to go to or bringing a level of expertise up is a really important part of the puzzle. Good. Yeah. Thank you. Thanks, Dr. Spencer.