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Thread: Fundus Photos

  1. #26
    What's up? drk's Avatar
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    Better'd review that policy, Cassandra, and quickly!

  2. #27
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    Cassandra, I too, amd curious about your response. Do you not charge different fees for different levels of service? Maybe I was confused by your response.

  3. #28
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    We typically don't charge for dialations, photos, or visual fields. If the doctor feels that it is needed, we do it. It falls under his regular (comprehensive) exam policy. We do charge for CL fits (new wearer or changing lens) and do specify differing levels on office (red eye) visits.

    We have just one price for progessive designs (use varilux, Zeiss, Shamir).
    One price for A/R (Crizal, Carat, Carat Advantage, Semplice) except Alize (we do charge $10 more for that).

    As I have explained before. The doc I work for isn't in it to get rich. He just wants to make a nice living, spend time with his family, and play golf :) Many patients have been coming to our practice for over 20 years. Most of our new patients come from their referrals.

    Cassandra
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  4. #29
    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by Jubilee
    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.

    Cassandra
    I think what drk was getting at is that it sounds like you have 2 fee schedule for the same service.........one for insurance and one for private pay. If it's as you say " we do not charge extra if it is needed, though at times we may bill an insurance if it is allowable". That might be seen as fraudulent. In theory, you either have to bill it to all the same.......or not bill it.

  5. #30
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    To tell you the truth, I think we have only billed insurance once. It was for someone who we had to repeat multiple tests on due to a medication he was using. If he was private pay, he probably would have been charged as well.

    I just hate using the words always or never. There is always an exception.

    Cassandra
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    Not to sound prudish or "holier than thou" but I do have a problem with not dilating a patient who is there for a complete exam. I don't personally enjoy dilating patients and I can empathise with the inconvenience to them but I wouldn't feel right if I didn't do it. My feeling is that if the patient is there for a "complete exam" and you missed something significant in the retina, how could you justify not having done a dilated exam? If the patient is young, healthy and has large pupils so I can see most of the posterior pole with my small-pupil BIO, then I sometimes forego the dilation. If I don't get an adequate undilated view I will use Neosynephrine 2.5% after the refraction and send them to the optical shop. When the optician is finished dispensing glasses she will bring the patient back for the dilated exam. At this point, since neo 2.5% is extremely weak, the pupil is mid dilated and moderately reactive. If the patient is older, or darker skin or may have some type of pathology we use either a "weak mix" ( Neo 2.5% and Mydriacil 0.13%) or a "strong mix" (Neo2.5% and Myd 0.3). These allow for a better dilation than Neo alone and works for the vast majority of patients. We hardly ever go with anything stronger and we achieve good dilations. We always reverse with Pilo 0.25% at the end.

  7. #32
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    ilanh: Sending them to the optical shop, unless you do not have a financial interest in it is illegal (eyeglass 1, you know).

  8. #33
    Bad address email on file NC-OD's Avatar
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    delete

  9. #34
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    The problem with dilating all patients is that it can mess up their distance vision. If they have to drive very far it can be a serious problem.

    This happened to me. I had my eyes dilated a few months ago and my distance vision was only 20/50 with full correction afterwards. Even with my large very dark polarized sunglasses I had trouble with the bright sun. I only had to drive a little over 2 miles and it was very hard. Honestly, I was not safe to drive.

  10. #35
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    Guess I have been confused all these years. I have always believed that dillation messed up only near vision, except for glare succeptability. Possible exception being hyperopes that are undercorrected and using thier accomodation to achieve distance acuity.


    Chip

  11. #36
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    True... dilation can stuff up DV, and also be quite uncomfortable. However, if a good view of the retina (for example) is required, and it is not accievable without dilation, and the dilation is safe, then one ought to dilate. This might mean the patient comes back at a convinient time, with some sunglasses, and somone to drive them home

    I think that for a diabetic for example, dilation and fundus photography ought to be just about mandatory, and regular, if we want to offer the best patient care. Some retinal cameras are good enough not to warrant dilation in some cases, in those cases it is better not to. I have always gone on the dont dilate untill there is a need to
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  12. #37
    What's up? drk's Avatar
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    Yes, Cassandra, you have to bill all patients equally, regardless of their payment situations.

    Ilan, I think you are correct, of course. I routinely use 2.5% P as the dilating agent of choice for patients under 60 for routine vision exams, and 0.5%T for those 60 up. I will be honest and tell you that i gt 2.5% P on a kid is not going to improve my view of the fundus, but I do it anyway.

    How do you get the customized drops? They are not commercially available in my experience. You mix them up yourself?

    As to pilo, I've always understood that you increase the risk for acute angle closure by creating an antagonism in the iris muscles. I never reverse dilation, and I'm doing fine.

    As QDO1 says, there is no excuse to not dilate.

    Chip: Eyeglasses I? Come on!

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    Quote Originally Posted by NC-OD
    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 believe that if you specify each section of the exam as normal you would not have any problems. I don't think that you need a picture of the fundus to prove that it was normal, just as you don't need a picture of the cornea and conjuctiva to prove that they were normal.

  14. #39
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    Quote Originally Posted by NC-OD
    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..
    Actually, I don't think that I've ever seen routine photos in an M.D office. We have the camera and we take photos whenever there is a justification. Insurance will only pay for photos when you are seeing a new lesion or actively following a changing lesion. For example, you can't bill for routine AMD, or BDR that never changes. After all if you want to document a "normal fundus" why don't you also take pictures of the cornea, lens, lids etc and document them all as normal also.

    With regard to your comment on the $400 LRI (limbal relaxing incisions) during cataract surgery, I think it is unrelated. I also charge this fee and it requires a lot of additional work. First, we obtain a corneal topography, automated K's AND manual K's to verify the steep meridians. Then we do both an IOL Master and immersion A-scan to 100% verify the implant power. Then there is some cognitive work that goes into planning where the cataract and LRI incisions will take place. At the time of surgery we do the incisions using a diamond blade and markers. The postop course is somewhat more extended because we can't do our refraction at 2 weeks as we usually do (the incisions take longer to heal), so we refract again at 1 month to check for stability. The end result is usually a patient who is seeing postop without glasses because his astigmatism has been neutralized. Is that worth $400?

  15. #40
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    perhaps im struggling with this thread because the US and UK staff / practice / testing systems are different to each other?
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    Quote Originally Posted by chip anderson
    Guess I have been confused all these years. I have always believed that dillation messed up only near vision, except for glare succeptability. Possible exception being hyperopes that are undercorrected and using thier accomodation to achieve distance acuity.


    Chip
    I thought the same thing. When patients complained that it messed up their distance vision I didn't really believe them. :o

    I tested myself with an eye chart. I normally see 20/15 corrected and I was seeing 20/50. I am not a hyperope, I wear about a -2.50 for distance.

  17. #42
    Bad address email on file NC-OD's Avatar
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    Quote Originally Posted by ilanh
    I believe that if you specify each section of the exam as normal you would not have any problems. I don't think that you need a picture of the fundus to prove that it was normal, just as you don't need a picture of the cornea and conjuctiva to prove that they were normal.
    The problem with specifiying "normal" is that your normal and my normal might not be the same. I'm in a military town so I see alot of people coming and going. Is their 0.45/0.45 cupping normal for them or was it 0.20 a few years ago? Is their lack of a macula reflex normal for them or was there a bright shining reflex before? That kind of stuff.

    I'm not really talking about taking a picture. I only do it when medically necessary (but I disagree with not being able to photo retinopathy unless it's changing). I was just talking about writing 'normal' on a chart. I don't think Medicare will accept "normal" on any finding........at least that's the way I learned it.

  18. #43
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    Quote Originally Posted by ilanh
    Actually, I don't think that I've ever seen routine photos in an M.D office. We have the camera and we take photos whenever there is a justification. Insurance will only pay for photos when you are seeing a new lesion or actively following a changing lesion. For example, you can't bill for routine AMD, or BDR that never changes. After all if you want to document a "normal fundus" why don't you also take pictures of the cornea, lens, lids etc and document them all as normal also.

    With regard to your comment on the $400 LRI (limbal relaxing incisions) during cataract surgery, I think it is unrelated. I also charge this fee and it requires a lot of additional work. First, we obtain a corneal topography, automated K's AND manual K's to verify the steep meridians. Then we do both an IOL Master and immersion A-scan to 100% verify the implant power. Then there is some cognitive work that goes into planning where the cataract and LRI incisions will take place. At the time of surgery we do the incisions using a diamond blade and markers. The postop course is somewhat more extended because we can't do our refraction at 2 weeks as we usually do (the incisions take longer to heal), so we refract again at 1 month to check for stability. The end result is usually a patient who is seeing postop without glasses because his astigmatism has been neutralized. Is that worth $400?
    I trained in an ophthalmologist office..........that's where I learned to code aggressively. It's where I learned to recall many patients every 4 months and where I learned to send the 20/25 cataract patients with 20/400 "glare" vision in for surgery and where I learned to train a tech to do all the refracting. :bbg:

    Seriously, I'm not disputing the benefit of an LRI....just the fear tactics some OMDs use to get patients to pay for it. Telling them they will not be able to see well after surgery unless they have it done is not the same as saying, "you will see fine afterwards but you may still need glasses to correct your astigmatism". The aggressive ophthalmologists around here convienently leave that part off :o No big deal to me but I have to listen to the patients when they return for post-op tell me about they were pressured at the last minute to have this done (Billing Clerk right before surgery: Dr. Smith said you will need a LRI procedure and by the way, Medicare doesn't pay for it. Will that be cash, check or charge).

    I do all the one-day post ops for my patients. I have seen some great things with the Crystalens (and some not so great things). Haven't seen a Restor lens yet but it's being pushed in this area. I can't say I am greatly impressed with some of the LRI's I see. Probably 50% have little to no reduced astigmatism. The most impressive I've seen was on a keratoconus/cat surgery patient.

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    Sounds like you're working for a VERY agressive ophthalmologist. I don't think I've ever done a 20/25 cataract. And I do not do any glare testing. ALmost all my cataracts are 20/50 or worse. Rarely, I may have a 20/40 patient who is very symptomatic. With regards to your observations regarding LRI it is interesting that you're only seeing results in 50% of your patients. Are you refracting them at least 1 month postop? The refraction does shift a lot in the first month. Are you actually seeing the incisions? Is he making the incisions based on topography or simply based on manual or automated K's? ALso, you mentioned that you saw a good result in a Kconus patient. However, LRI is definitely contraindicated in Kconus. I'm not getting 100% on LRI either but 50% sounds much too low.

  20. #45
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    Quote Originally Posted by ilanh
    Sounds like you're working for a VERY agressive ophthalmologist. I don't think I've ever done a 20/25 cataract. And I do not do any glare testing. ALmost all my cataracts are 20/50 or worse. Rarely, I may have a 20/40 patient who is very symptomatic. With regards to your observations regarding LRI it is interesting that you're only seeing results in 50% of your patients. Are you refracting them at least 1 month postop? The refraction does shift a lot in the first month. Are you actually seeing the incisions? Is he making the incisions based on topography or simply based on manual or automated K's? ALso, you mentioned that you saw a good result in a Kconus patient. However, LRI is definitely contraindicated in Kconus. I'm not getting 100% on LRI either but 50% sounds much too low.
    Yes, I agree he was what you call 'aggressive' or gung-ho...maybe even greedy, depending on who you ask :). I also worked briefly at a VA hospital and the one older ophthalmologist wouldn't do a cataract surgery until the people were walking into wall (a slight exageration.......but not much). And when he finally did, they were many times a disaster. One thing I learned there is that not all cataract surgeries or surgeons are created equal, for sure.

    So really, I guess it just goes to show you can have questionable ethics on all sides (back to the original photo question). By the way, the K-cone lady was best-corrected to 20/50 before cataract surgery (and LRI.......actually most call it CRI-- corneal relaxing incision around here for some reason), and is 20/40 post op after a year--with no rx worn. She is thrilled (20/happy, I guess ;) ).

    Interestingly, I can break down the 14 or so Ophthalmologists around here like this: 2 are very pro-Optometry (they stay busy doing lots of surgery and couldn't care less how much glaucoma I treat), about 8 are neutral-meaning they will not spit on me if I see them in public (will co-manage or at least send the patient back after the post op), and 4 that think all ODs are grade-school graduates that need help spelling glau-co-ma.:p

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    We offer the Optomap in our office. It is 25.00 extra. The patient reads about photo and signs if they want it or not.

    It takes a 200 degree image of the back of they eye. We are able to save photos and compare the pics yearly.

    We have found early retina tears, blockages and other problems. Pretty interesting. Anyone else have one?:D
    karenrp1956:drop:

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    Interesting discussion about use of non-mydriatic fundus photos, but I don't see anything about use of the instrumentation in telemedicine. With a country the size of Canada, the sparsly populated Northern country can potentially be served by use of the instrumentation by a tech or nurse and the image transmitted to an ophthalmologist anywhere in the world for evaluation. Some retinal disorders are a serious concern among the first nations populations in remote areas, (diabetic retinopathy) ( can also work with X-rays, EKGs ect.) I'm curious. what are your thoughts? Is there a place for this in areas not traditionally underserviced by medicine?

  23. #48
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    Dave,

    That's an interesting thought. A couple of years ago, I attended a photography seminar by Ben Szirth, an ophthalmic photographer at the New Jersey Medical School in Newark. A good portion of the seminar discussed telemedicine, specifically screening for diabetic retinopathy.

    There are obviously issues of file security and maintaining photo integrity. You'd also have issues of compatible software at capture sites and review sites. I remember when we bought our fundus camera, the technician discussed the type of monitors he was installing, so I guess that would be an issue for a telemedicine set-up.

    I think this kind of technology could have a strong role in underserviced area. I'd be very interested to hear from anyone who has experience in telemedicine.
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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?
    As I understand it, we're not supposed to talk fees here, but then I always question authority and proceed with what I think is right. You can see how I handle it by going to http://www.folsomeye.com and can see an example of the Canon system I use. In a nutshell, I charge when I can, but I always do a baseline photo, always.

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    Quote Originally Posted by ilanh
    Sounds like you're working for a VERY agressive ophthalmologist. I don't think I've ever done a 20/25 cataract. And I do not do any glare testing. ALmost all my cataracts are 20/50 or worse. Rarely, I may have a 20/40 patient who is very symptomatic.

    I think you're being very conservative, as are most omds I know. I think you guys should feel free to suggest/offer surgery to any presbyopic hyperope who shows early cataractous changes. I don't know how aggressive the insurance cos. will allow, but I'd recommend pushing the envelope.

    With regards to your observations regarding LRI it is interesting that you're only seeing results in 50% of your patients. Are you refracting them at least 1 month postop? The refraction does shift a lot in the first month.

    I think the smaller clear corneal incisions today result in much less variation in refraction post-op. I had very little change in my refraction after week 1.

    Are you actually seeing the incisions? Is he making the incisions based on topography or simply based on manual or automated K's? ALso, you mentioned that you saw a good result in a Kconus patient. However, LRI is definitely contraindicated in Kconus. I'm not getting 100% on LRI either but 50% sounds much too low.

    I also had LRI although my surgeon had to convince me, esp. since I knew I'd be wearing specs post-op. They worked pretty well as I went from a 3 cyl to a 1.00 in one eye and .25 in the other.

    Although i waited until one eye was approaching 20/50, I jumped at the chance of doing the other eye that was still 20/25. And if I'd known then what I know now, I'd have insisted on doing it a year earlier.
    (mine were done in Jan 05 by David Chang)

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