I.
Co-management History
A.
1986-1987-The Budget Reconciliation Act, Medicare and the Heinz hearings
B. Inspector General investigation in 1987
C. 1987 shift to state activity in North Carolina, Iowa and California
D. 1998-1999 Medicare Carrier policies in Kansas, Connecticut and New York
E.
F.
G.
2000 New York shifts and Trailblazer policies in Maryland, Texas, District of
Columbia and Delaware
Inspector General ruling on “Safe Harbor” regulations related to co-management
New state legislative initiatives targeting medical licenses in Missouri and Florida
II.
The Association Effect
A.
Position paper by the American Academy of Ophthalmology (AAO) and the
American Society of Cataract and Refractive Surgeons (ASCRS) in February 2000
B.
The American Optometric Association response in April 2000
C.
The Society for Excellence in Eye Care (SEE) response in April 2000
D.
The International Society for Refractive Surgery (ISRS) response in July 2000
III.
Legal Issues of Co-management
A.
Is the optometrist licensed to perform the services needed?
B.
Is co-management a kickback?
C.
Who pays the bill?
D.
How is the value of the service determined?
E.
Is there an agreement to refer?
F.
Is cataract surgery co-management regulated but refractive surgery not?
IV.
What should the optometrist that desires to co-manage today?
A.
Informed consent a necessity today!
B.
Should include a statement of choice of provider for the post-operative care
C.
Should include financial disclosure
D.
Needs to be in writing-several options and examples provided
E.
Both providers need copies of consent in the patient’s record
F.
Sample consent wording provided
V.
There needs to be a clinical basis for co-management
A.
The optometrist should observe surgery on all procedures they wish to co-manage
B.
The optometrist and surgeon should share post-operative care to develop care protocols and develop a comfort level
C.
The two professionals should develop written protocols for the post-operative care
D.
This will help avoid the “Negligent Referral” lawsuits that are possible for both sides and the “Abandonment” claim for the surgeon
VI.
Components of a successful co-management relationship
A.
Trust
B.
Confidence
C.
Communication a.
Forms b.
Timing c.
Coding d.
Meetings e.
Continuing education programs

D.
Staff
VII.
The clinical side of co-management
A.
Pre-operative care a.
Patient selection b. Pre-operative testing
B.
Post-operative care a.
Manage infection b.
Manage inflammation c.
Manage intraocular pressure d.
Manage incision site e.
Monitor refraction f.
Monitor retina g.
Manage core factors i.
Complaint solved by surgical procedure ii.
Making sure the condition remains solved iii.
Monitor for complications of any kind iv.
Pain management
VIII.
Medications in post-operative care
A.
Antibiotics
B.
Anti-inflammatory a.
Steroid b.
Non-steroidal
C.
Combination antibiotic/anti-inflammatory
D.
Cycloplegics
E.
IOP lowering medications
F.
Analgesics
IX.
Anterior segment surgical co-management-complications
A.
Flat chamber
B.
Low IOP
C.
IOP elevated
D. Late phase IOP elevation
E. Infection
X.
Cataract co-management
A.
Pre-operative testing a.
Biometry w/IOL power calculation-CPT 76519 b.
–26 and -TC modifiers
B.
Post-operative codes a.
CPT 66984-55, 66982-55, 66985-55, 66986-55 and 66821-55
C.
Post-operative care a.
Tests b.
Care frequency
D.
Complications a.
Physiological b.
Optical
E.
YAG capsulotomy

XI.
Refractive surgery co-management
A.
Post-operative fee calculations-risk and work performed
B.
LASIK a.
Pre-operative i.
Corneal thickness ii.
Corneal curvature iii.
Pupil size b.
Post-operative i.
Tests ii.
Care frequency iii.
Complications
C.
Phakic IOL-anterior chamber a.
Pre-operative i.
Anterior chamber depth b.
Post-operative i.
Tests ii.
Care frequency iii.
Complications
D.
Phakic IOL-posterior chamber a.
Pre-operative i.
Anterior chamber depth b.
Post-operative i.
Tests ii.
Care frequency iii.
Complications
XII.
Glaucoma surgery co-management
A.
Laser procedures a.
Post-operative codes-CPT 65855-55 b.
Argon Laser Trabeculplasty (ALT) i.
Post-operative care and complications c.
Selective Laser Trabeculoplasty (SLT) i.
Post-operative care and complications
B.
Non-penetrating deep sclerectomy a.
Post-operative codes-CPT 66170-55, 66180-55 and 66250-55 b.
Post-operative care and complications c.
YAG goniotomy revision
C.
Trabeculectomy a.
Post-operative codes-CPT 66170-55 b.
Post-operative care and complications
XIII.
Retinal surgery co-management
A.
Procedures with most post-operative care referred back to optometrist a.
CPT 67210 and 67228
B.
Procedures with some post-operative care referred back to optometrist a.
CPT codes 67141-55, 67145-55, 67220-55, 67036-55, 67038-55 and
67040-55
C.
Procedures with little post-operative care referred back to optometrist a.
CPT 67107, 67108 and 67110
D.
Post-operative care and complications

Conclusion:
A.
Co-managed care is an advantage or everyone involved
B.
Patients desire guidance in selecting the care process and surgical provider
C.
Optometrists need to select quality referral resources that desire to provide high quality surgical services and specialize in this area of care
D.
Need to base the c-management plan on a clinical basis
E.
Develop a “system” for co-management with the surgical practice
F.
Communication is critical to success, particularly early in the relationship
G.
Think broadly as most surgical procedures can be co-managed, not just cataract and refractive surgical procedures