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Thread: Fundus Photos

  1. #1
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    Fundus Photos

    What are most people charging for fundus photos?
    Are you using them for medical necessary only or as an additional service offering it to all pateints as an increased level of care for an aditional fee?

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    Quote Originally Posted by milesdavis
    What are most people charging for fundus photos?
    Are you using them for medical necessary only or as an additional service offering it to all pateints as an increased level of care for an aditional fee?
    Primarily doing photos in medically necessary cases. Most patients, coming into my office anyway, are expecting their visit to be covered by their medical and or optical insurance. So, we get the attitude from the patient that if my insurance won't pay for it, then it's really not necessary.

    The fact is, if it is necessary, then medical insurance will cover it. IMHO.

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    Once upon a time this was done by the local independent optical shop as a public service (no charge). Now it's a way to "boost revenue." Other than a historical record for some specific conditons I don't really see it haveing any other purpose.

    I can remember when I would see patient's with detachment seeing 20/80, the doctor sent them to Alice McPherson and they came back seeing 20/30. Then they started sending them to New Orleans and Memphis. They came back seeing 20/80 but praising the doctor's office for how modern it was and how many picutures the doctor took.

    Are we sure we are evolving in the right direction?

    Chip

    How is taking retinal picutures an "increased level of care" on a healthy patient?

  4. #4
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    There was a recent case where a OD was charged for missing Wet ARMD. He routinely does fundus photos that backed up that the patinet developed after the visit.

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    Note: This was one case. Note: This was an added protection for the examiner, the patient did not realize any "added service" or "added benefit."

    It's a damn revenue builder unless some pathology is present. It might be a benefit if something was suspected and copies sent to some institution with greater expertise, but I doubt this is the case when photos are done as routine exam fodder.

    Chip

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    Wanting to increase revenue is a problem? In today's society where people will sue for spilling hot coffee on themselves. If i can provide and increased level of service and oh yeah "wow" the patient with it seems logical to me.

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    We used to use. . .

    the old polariod fundus camera that flashed as bright as all outdoors. 5 years ago we switched to digital images that are easier to save and to transmit. We don't charge for taking pictures and it is routinely done on all patients.

    The Dr is an older doc that also dilates everyone, every year need it or not. That's just his comfort level and now that his practice has grown old with him we see alot more glaucoma and other age related diseases. This is just the standard of care he has set for his patients.

    I'm not a Dr, I don't even play one on tv. If my Dr feels that this is what his patients need. Or if this is what Dr needs to feel that he's done the best for his patients, then God bless him. I don't feel the need to judge him.

    I don't think that it has hurt the practice. In the long run I think his reputation has been enhanced and that alot of people come to see us because of his thoroughness.

    I hope you're all having fun and making money!! :)

  8. #8
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    We offer pictures and visual fields as an option for the patient. There is a sheet of paper that explains the tests and asks if the patient wants it done. The price is clearly marked and it states that optical insurance doesn't cover it.

    If the patients have questions we tell them to mark it with a question mark and discuss it with the doctor.

    We charge $18.00 for the pictures and $24.00 for visual fields.

  9. #9
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    I am very ambivalent regarding the routine visual fields and fundus photos that are so prevalent in optometric practices. Let me assure you, as a board certified fellowship trained glaucoma specialist, that there is absolutely no reason whatsoever to do a visual field on a normal individual who has normal IOP's and optic nerves. I don't see any justification for it other than the billing. Occasionally the visual field will catch an homonymous hemianopia or some other neurological defect which usually represents an old stroke. I have never seen it detect glaucoma that I wouldn't have detected otherwise. However, I have seen numerous cases in which a "suspicious" field was sent for exhaustive workups which never benefitted anybody. I simply don't feel that they're necessary and would suggest that optometrists stop doing them.

    Secondly, I cannot see any justification for routine fundus photos either. I dilate every new patient that I see, every patient with pathology and any patient coming for an annual visit. If the patient is young, is there only for refraction and has big pupils I will use my small pupil BIO to get an adequate look without dilation. Therefore, I can't really justify doing and charging for a fundus photo which will not help me in any way.

    I would love to find ways to increase practice revenues but I simply can't bring myself to recommend these to my patients. If there was even a bare iota of evidence that they help in any way I would leap upon it in a moment (I have all the equipment in my office and would use it on everyone if it helped).

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    I am very glad that this topic has been brought up and that there is a board certified physician on this forum who is speaking on this matter.

    For the past couple of days I have been trying to find empirical data that supports the efficacy (or usefulness) of fundus photography. I am currently employed in an "independent" optometrist's office that is owned by a large corporation. We charge $19 for a fundus photo that is separate from our basic eye exam. Our doctors are ambivalent about the photos and I have never personally seen them use them in any sort of capacity. One doc even admitted that it was hard to distinguish certain pathologies due to the limited resolution of digital cameras. Yet, the powers to be have set up strict quotas that are to be met irregardless of the patient's condition.

    The reasoning given to me for such number padding is that we need a "baseline" of the patient's retina every two years. "We use it for note taking purposes; just like they say a picture is worth a thousand words" , or so I was told. Does this sound at all like a reasonable justification for this procedure?

    I would love to be able to show my managing optician/boss that this push to drive up numbers for the sake of increased profit revenue is not beneficial to the patient. Any suggestions???

  11. #11
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    A majority of the time when we toke photos it was not used for anything other than just a record of what was seen. The doctors prefered the patient be dialated anyway and the photo was to just keep track of any condition that was found. It was rare that we took photos and most the time it would be because the doctor wanted a kind of trophy of what she saw, and would not charge for it anyway.
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    Bad address email on file NC-OD's Avatar
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    I was not aware than so many Optometrists charge for routine photos. I don't know this to be true. I do not take routine photos. Also, I have heard that that screening fields may one day soon become 'standard of care' (for whatever reason).

    I do know some ODs and OMDs that routine take photos during work-up and digitially zoom them to the exam rooms. There is no charge for this but used more for patient education. There is nothing like showing a pt the retina vs. trying to explain it to them.

    I'm a little dissappointed it Ilianh's assertions that so many ODs are trying to rip people off. I'd venture to guess that as many OMD offices are taking routine photos as ODs.:) I've got a cataract MD that is billing level 5 consults on every routine cataract eval I send him, doing an OCT on about anyone that will sit still AND trying to upgrade every patient I send him into the Crystalens with an additional $400 LRI. You get all types:shiner:

    I wouldn't worry about the photos as long as they are optional and the patient knows this. Some people get a kick out of having a retinal photos to show friends and family.

  13. #13
    Bad address email on file fvc2020's Avatar
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    In our office we offer to patients the opportunity for photos. We do charge $35.00. We have a form for them to read and a book of photos taken to show what we see. We are specific when it comes to diabetics, glacoma, etc and a family history of specific said problems. We also advise that if a medical dx is found we will bill the insurance and if possible we will get a refund for them or direct reimbursement.

    We can bill photos with most insurance in the area for up to $120.00. We don't. Patients have the right to have the best of technology. Some people like having baselines on file if problems arise in the future. My doctor likes have a record of progression in cases of diabetes etc. Photos are not a waste. When we refer we can send the photos by mail or internet(if the MD has the ability), and there be very little confusion over why we refer.

    Is this a revunue builder? It could be, if we charged more. We make our lease payment and maybe a little more, but that is it.

    christina

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    The issue of "baseline" photos has been brought up. My baseline of a normal dilated fundus exam is simply stated in my notes, "...normal discs, maculae and vessels...". If in the future I see a change I would then obtain retinal photographs. I don't think that obtaining normal baselines is the standard in medicine. If it were we would be inundated with "baseline" CT's, blood testing, angiograms etc etc. We are beginning to confuse the concept of a baseline with that of a screening test. A screening test is designed as a quick and simple diagnostic test that may detect an otherwise harmful condition. In that sense, mammography or Pap smear is an ideal example. However, when you do a fundus exam you have already verified that there is no pathology and therefore you have screened out potential pathology. Likewise, a baseline test is one in which pathology is detected and is being monitored. For example, a choroidal nevus may merit a baseline photo to document it's size. This could then be compared at a later stage. However, it is not acceptable in medicine to tell a patient, "your lungs sound perfect but I would like to obtain a baseline chest Xray so that we can establish a baseline."

    Incidentally, regarding the comment about the level 5 consults for cataract. If you can believe this, I have never billed a level 5 consult in my entire career. I don't even have it on my superbill. If you know an M.D who is billing level 5's for cataract I am amazed that he has not been audited by CMS and shut down.

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    Master OptiBoarder ziggy's Avatar
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    Medicare has set the reimbursment rate at $71.80 (both eyes). As long as you stay there abouts I think thats fair. The good thing about the photos is that you can build revunue, increese the level of care and cover you butt all at the same time. As for as using it as a base line.. dont lie to your self, most patients will only be with a Doc 3-5 years so if the retinal changes 15-20 years down the line your photos will be useless. BTW there is nothing wrong with making a profit.
    Paul:cheers:

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    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by ilanh
    The issue of "baseline" photos has been brought up. My baseline of a normal dilated fundus exam is simply stated in my notes, "...normal discs, maculae and vessels...".
    I have always been taught that retinal findings should be documented with a bit more detailed findings such as a specific c/d ratio, FLR, AV ratio etc.... . I wouldn't feel comfortable with regards to audit status or my personal pucker factor just putting down "normal" on most any findings. I have seen this in some older charts. I have seen charts from retired docs (and a few not-- but probably should be--retired ones) with little more than a VA check, an IOP and "ocular health Okay" jotted on an index card. Must have been nice back in the day :) Hey, I even know a glaucoma specialist that never picks up a pre-corneal lens. He judges every C/D ratio with an old direct scope.....He's better than me, I guess.

    But I do agree that those offices pressuring (or implying a higher level of care) for screening photos are probably wrong. But now some have the super-duper Optos. I guess that's a whole other story.:cheers:

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    There is something very, very wrong with making a profit by ordering tests, and proceedures that are not indicated and hold no benefit to the patient.


    Chip

    For those of you who don't see this or say: We just bill the insureance "(for which we all must pay higher rates, there is something very, very wrong with you!

  18. #18
    Bad address email on file NC-OD's Avatar
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    I agree with Chip (this rare time). It's wrong unless the ordered test was offered as an obvious option to the patient and they freely chose to have it done as in the case of routine photos (at least that's how I hope they are offered).

    My wife was recently offered to 'upgrade' her mamogram to a new-fangled digital version that was "better". It costs her an extra $30 over her copay. I wonder if that was right for the OB group to do this?

    Come to think of it, is it okay to offer to upgrade to a Solamax progressive when a regular SNL would allow the patient to see well enough? Why do a Limbal Relaxing Incision (LRI) when a pair of astigmatic glasses would allow the patient to see fine after surgery?

    -- Telling the pt they won't be able to see well unless the LRI is done or....
    -- Telling the pt they won't be able to read well unless they get a fancier (ie higher profit margin) progressives or.....
    --Telling the patient that you will find something on a photo you can't see with your naked eye.......

    .................is all wrong without informing them of the options.

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    Master OptiBoarder ziggy's Avatar
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    Its all about the option, and again I say there is NOTHING wrong with making a profit. How many have sold a SRC knowing that int already comes on the lens? At least with testing, as long as the patient has the option, you can rule out things. Sales is sales.
    Paul:cheers:

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    Dah is options benficial to da patient and dah is options benficial to practioner.

    Are we in the sales business or the medicine business?

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    fundus photography is clearly beneficial to the patient who is loyal, and comes back year after year. Ophthalmoscopy is good enough to know there is a problem, but the year on year photo may be more revealing. fundus cameras are not cheap, and have a limited life. It is not unreasonable to charge a rate consumate with the amount of patients photographed Vs the lifetime of the equipement used + a small margin to reflect the risks made to offer the service
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    How does one explain to the patient the benefits of having a fundus photo on file after the doctor has just pronounced their retina 'normal and healthy'?

    Other than the coolness factor or the ability to educate the patient on what a retina looks like, most of the benefits (i.e. covering one's ***) are to the office and not to the patient or so it would appear to an inexperienced layman such as myself.

    I do not have a problem with fundus photography nor do I have a problem with profits. What I do have a problem with is increasing profit through means that masquerade themselves as increased levels of healthcare. Unless the doctor deems them medically necessary are we increasing the level of care with tests that have little to no intrinsic value to the patient?

    Speaking only of my corporation, are we that reliant on some test to boost revenues? Can we not focus on other aspects of the business, such as innovative marketing or building solid relationships with the patient/customer through superior service?

    Perhaps my thoughts are outdated but I always that members of the medical community had a fiduciary responsibility to the patient. That we should look out for their best interests as well as make some money on the side.

  23. #23
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    I agree with Ilan, mostly, but NC-OD makes a good point that it's not only the OD's who are out to turn a quick buck.

    The general concept of "elective medical care" is bad, IMO. Either the patient needs fundus photography (or visual fields, or even/especially dilated funduscopy) or they don't. Any Dr. that told me I could have "additional testing for an additional price, OR NOT" wouldn't be my Dr. any longer.

    Either people that aren't paying aren't getting the care they need, or the people that are paying for the extra tests are getting care they don't need. Which is it?

    Not suprisingly, the concept of elective extra testing was borne out of trying to get a good return on investment on expensive equipment. I saw a recent ad for a high-ticket diagnostic system that shows how affordable it is, if you do "x%" of exams for an additional "$x" in revenue per exam. The companies want to sell you equipment.

    I'm with you, Ilan, on routine VF screenings. Even though most OD's include this in the cost of their exam, it's not a high-yield screening procedure, and doesn't justify the time expenditure.

    P.S. As NC-OD apparently is aware, there have been anecdotal reports that the Optos can detect subtle lesions that BIO cannot. We'll see how that works out.
    Last edited by drk; 11-15-2005 at 09:21 AM.

  24. #24
    Bad address email on file NC-OD's Avatar
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    While we are on the topic--- Probably my biggest pet peeve is offices that have an optional fee for dilation. This is about the dumbest thing I have ever heard. Who wants to pay to be dilated? That's about like me having to pay someone to beat my ***

    It should be the docs call and should not be influenced by the ability of the patient to pay (or want to pay).

  25. #25
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    In our office, we only will do VFs, photography, and dialation if warranted during the regular exam. We do not charge extra if it is needed, though at times we may bill an insurance if it is allowable.

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