Straight Talk Regarding ‘Elephants in the Room’

By Charles B. Brownlow, OD

When I did my first presentation on medical record keeping after the release of the 1997 Documentation Guidelines for the Evaluation and Management Services (99000 codes), I was sure that the document would finally spur doctors and insurers to learn and follow the rules.  The ‘DGs’, as we refer to them, provide a very simple explanation of the logic of the delivery of health care services, followed by a very objective, detailed set of instructions for creating good medical records and for choosing 99000 codes accurately.

The word ‘objective’ in the previous sentence means that doctors and staff could choose codes exactly as insurers are required to choose them.  Doctors adhering to the definitions for services provided by the Current Procedural Terminology (CPT © American Medical Association) and the DGs would never have to worry about an audit by Medicare or any other insurer.  All a doctor would need to do for visits would be to provide the care the patient needs; no more, no less; keep an excellent record of all that happened during the visit, and then choose a code to represent the content of the record.

For the first time in history, the process of choosing visit codes can be accurate, objective, and repeatable, with those three characteristics ensuring appropriate reimbursement for services provided and ‘no hassle’ chart reviews or audits.  When I first read the DGs in July of 1997, I was ecstatic!  Our colleagues would no longer have to worry about choosing codes nor about being audited.  I was doubly ecstatic because the 1997 DGs were the first guidelines to provide guidelines customized for eye specialists.

The original guidelines required doctors to examine at least nine organs systems, actually doing at least two tests on each system for the physical examination portion of a visit to qualify as ‘comprehensive’. With the 1997 DGs, eye doctors could reach the previously acrophobic level of comprehensive physical examination (and thus the higher level codes that require comprehensive physical examinations) simply by doing twelve ophthalmic elements and two psychiatric elements (mood and affect and orientation to time, place and person.)

Furthermore, the required ophthalmic elements have traditionally been included in a typical eye examination; acuities, gross fields, examination of the adnexa, pupils and irises, motility and versions, corneas, anterior chambers, crystalline lenses, bulbar and palpebral conjunctiva, IOPs, and dilated ophthalmoscopy (discs and peripheral retina). Wow!  The 1997 DGs made it possible for eye doctors to appropriately choose the higher level 99000 codes; 99215, the 99204 and even the 99205 (albeit rarely); for the first time since CPT created the 99000 codes in 1992!

Being the eternal optimist that I am (or that I was in 1997), I assumed the 1997 DGs would be immediately embraced by ODs and OMDs, who would quickly learn of their simplicity and accuracy and objectiveness and repeatability, and would begin using them immediately.  Obviously, I could not have been more wrong.  Here we are, eighteen years after the introduction of the 1997 DGs, and the typical OD and OMD still don’t understand the power that the document provides them.

As a matter of fact, based on my experience with the hundreds of audiences I’ve faced during those years, I’m pretty confident in estimating that fewer than 30% of all eye doctors have ever read the 1997 DGs, even though a relatively high percentage of eye doctors use them in their practices every day!  Talk about self-destructive behavior.  Without understanding the DGs, it doesn’t matter whether the doctor, the doctor’s staff, or the doctor’s EHR software is choosing the codes, the audit will be ugly.  Even worse, without knowledge of the DGs, the doctor and staff will be helpless in attempting to defend themselves in an audit…Even though the auditor probably doesn’t know the DGs well, either.

As long as we’re getting depressed, let’s consider another ‘elephant in the room’, probably larger than the DG issues.  Thousands of eye doctors in the US are reporting their visits to insurers using the comprehensive ophthalmological services (CPT©AMA codes 92004/92014), without knowing the definition for those services.  Let’s do a little math.  If we assume that 40,000 eye doctors in the US are each using these codes 2,000 times per year, that would represent 80 million uses of that code per year.  If we generously assume 50% of those doctors actually have read the CPT definition, understand it, and appropriately apply it, that could mean up to 40 million potential incorrect choices of the code every year.   Imagine the potential impact on these two professions that a sweeping audit of those two codes would produce.  40 million incorrect claims, even at $100/claim would be $4 billion!

Will thoughts such as these get the attention of America’s eye doctors and staff?  Will thoughts such as these get the attention of American insurers? Sadly, I’d bet on the latter before the former, though it is clearly the former; America’s eye doctors; that I have devoted my professional life to.

What can be done about this?  What can the AOA and AAOphthalmology do?  What should the educational programs for tomorrow’s doctors of optometry and ophthalmologists do to correct these issues?  I believe it starts where it should have started back in 1997; with the practicing doctors.  It starts with downloading a FREE copy of the 1997 Documentation Guidelines for the Evaluation and Management Services from the CMS website;  It starts with buying the 2015 American Medical Association Current Procedural Terminology from AMA ($114.95), 800-621-8335) or at a member discount (approximately $100) through the American Optometric Association (, 800-991-4100).  AMA is the only CPT that is the national standard for procedural coding, so don’t mess with substitutes…They cost more and you cannot defend yourself in an audit without the official AMA CPT.

In short, no more excuses.  Just reading the first few pages of the AMA CPT and the 1997 DGs will help docs and staff understand the key links between excellent patient care and excellent records.  In my opinion those two documents should be ‘required equipment’ for all eye doctors and all future eye doctors.  CPT is only good for twelve months, so new copies must be ordered each December for the coming year.  I know, I know, $100/year seems like a lot of money to some, but measured against the huge, looming expense of ugly audits, it’s ‘peanuts’!  Let’s face it, CPT and the DGs; though they’ve largely been ignored by health care providers for decades; are priceless.

Please don’t put it off another 18 years.  Act today!

A Follow- up on Direct Messaging

**A follow up to an earlier Blog post by Dr. Snow (Patient-portals-and-direct-messaging-how-do-they-affect-me) 

By Dr. Jay Henry,

Q: How would direct email messaging assist optometrists?   Explain why it’s important for ODs to talk directly with the primary care physician (PCP) through  Direct protocols.    What could optometrists share that would be mutually beneficial to other physicians?

A: Direct messaging would allow optometrists, the primary eye care providers, to discuss results and information of shared patients with PCPs and other specialists.   Every diabetic patient gets a report sent to the PCP with results of the eye exam.   Many times it is the Optometrist who makes the first diagnosis of Hypertension, Thyroid disease, Diabetes, MS, high cholesterol, strokes, and  other systemic conditions.   When these situations occur, Optometrists need to be able to reach out to the patient’s PCP to coordinate care.

Optometrists also see many patients who need to be sent to a specialist or ophthalmologist.   ODs refer patients to a specialist / sub specialist and need to send  the testing results from the patient’s office visit or a clinical summary from their office visit.   A great example is when a patient is sent to a cataract surgeon for cataract surgery.   ODs do the majority of the patient’s pre-op testing and the post-op care from day 1 after the surgery.   ODs need to share this information back and forth with the surgeon.

For a patient with a retinal concern the OD may need to send clinical notes, photos, images, visual field results, OCT results and other information to the retinal specialist so the patient may receive further treatment or surgical intervention.     

All of these could be done via direct messaging.

Q: My eye doctor will be examining my eyes next week, and my neurologist wants him to test me because I’ve had an increase in migraines recently. He said he wanted to know about my “pressures.” Can you explain what this means?

A: This scenario would be the same for an Optometrist or Ophthalmologist.   Often a specialist or PCP wants  further testing done on a patient that the specialist or PCP may not do.   In this case the neurologist is concerned that  intraocular pressure is high and causing headaches to be worse or that preventative medicine you are taking is causing your eye pressure to be high and this can cause vision loss which is the disease of glaucoma.

Medical Homes are the Best Source of Reimbursement for Optometrists

By Mark A. Ridenour

This could very well be a headline in the future given the direction of changes in the healthcare industry today.  Many Primary Care Physician (PCP) practices have converted to the Patient-Centered Medical Home (PCMH) practice model.  There are now more the 7000 accredited Medical Home practices nationwide with 535 in Ohio.  PCPs have embraced this model because it allows them more practice freedom, offers the opportunity for increased reimbursement, improves their patient’s outcomes, and increases their patient satisfaction; not necessarily in that order.  PCP practices must meet numerous criteria to be considered a Medical Home, including 24-hour remote patient access, next day appointments, coordination of patient’s care with other providers, and team-based provider care with specific expertise around nutrition and behavioral change.  Physicians who have successful migrated to this model report greater job satisfaction themselves, because they are put into more of a CEO role, where the more complicated cases and decisions come to them and more routine care is seen by mid-level staff.  Patient response to this transformation has been mixed, but many insurers are now incentivizing their members to use Medical Homes via reduced co-pays and benefit design.

Payers (insurance companies, employers, and government) have discovered PCPs operating as Medical Homes lowers their costs.  Reducing emergency room admission rates and eliminating duplication of diagnostic tests are examples of quick payoffs.  Typically, they will pay these practices extra for care coordination and case management and/or pay bonuses for improved patient population health outcomes.  Many payers have shifted their risk to the Medical Home; i.e., they have given the Medical Home a percentage of the employer/employee premium to manage the patient.  The Medical Home, in turn, must manage the expenses of the patients, leading them to become more discerning about referrals.  Insurers will supplement this because a parallel objective they have is to reduce the most expensive care they pay for – hospital and specialty care.  This is one of these reasons the OOA continues to stress the importance of your relationship to your PCP referral sources.  Medical Homes will likely establish criteria for referrals to Optometrists.  Which practices supply me with the best and timely information about my patients?  Do I consistently receive exam results on my diabetic patients?  Are they encouraging them to maintain healthy behaviors?  Are they accessible for eye care emergencies?

This movement in the provider payment landscape is part of the reason the OOA continues to promote the Optometrist as the primary eye care provider.  Along with dental and behavioral care, optometric services are generally perceived as essential preventive care.  As long as fee-for-service reimbursement dominates, it is beneficial to be aligned as a primary care provider.  Payers are favoring reimbursement codes for these services over specialty care codes.  Plus, any alternative payment models will be based on the premise of investing in preventive care to avoid greater catastrophic costs.

So you may not be getting reimbursement checks from PCPs yet,….. but it may not be far down the road.  Now is the time to recognize this shift and solidify our relationships via active interactions and demonstrations of value.  Are PCPs likely to value Optometrists more than the insurance companies?  Now is the time to start influencing the answer.

For more information on the Medical Home model and specific information on those in Ohio go to the Ohio Department of Health website at

State Innovation Model – 75 Million Reasons to Pay Attention

By Mark Ridenour

In December, the Center for Medicare and Medicaid Innovation (CMMI) awarded a $75 Million four year grant to the Ohio via its State Innovation Model (SIM) awards to implement a payment reform model which will broadly move reimbursement models to recognize outcomes over volumes.  Providers will get increased reimbursement for providing more efficient care while maintaining or improving quality.  Ohio budget projections suggest another $125 Million in state funds could be added over the life of this project.  The stated SIM goal is to have 80-90 percent of Ohio’s population in some value-based payment model within five years.

The Ohio Office of Health Transformation (OHT) led by Director Greg Moody will manage this project.  There are two primary vehicles designed to work together to implement this change: 1) Episodes of Care and 2) Medical Homes.  (see chart below) The state will require each of the managed Medicaid insurers (CareSource, Buckeye, Molina, Paramount, and United) to participate along with the four largest commercial insurers (Anthem, Aetna, Medical Mutual and United).  In 2015, these payers will share data with providers on selected Episodes and begin to change payments in 2016.  The initial Episodes are Perinatal, Asthma acute exacerbation, COPD exacerbation, Percutaneous Coronary Intervention (PCI), and total joint replacement.


There are now over 500 accredited Medical Homes in Ohio.  This project will initially work with the 75 Medical Homes in the Cincinnati-Dayton region already engaged with the Comprehensive Primary Care initiative (CPCi), additionally funded by CMS.  This will progress by region in Ohio most likely taking advantage of the significant work already accomplished by the health collaboratives, Better Health Greater Cleveland and the Healthcare Collaborative of Greater Columbus.  The OOA has been a supportive participant over the past few years, although optometry has yet to demonstrate an impactful relationship.

Capture 1This chart represents the variability in total costs across an episode and how the OHT envisions introducing risk and gain sharing.  While the initial episodes chosen do not directly involve optometric care, we are confident that as the list grows to the expected 50 episodes they will likely include diabetes, glaucoma and/or cataract care.  The OOA has been engaged with the OHT so will be part of the stakeholder groups helping to shape this effort.

What can you do now to prepare for the changes brought about by this significant investment in the State Innovation Model (SIM)?  1) affiliate with Medical Homes and 2) maintain an Electronic Health Record (EHR) which meets Meaningful Use standards.

The best position for optometry as the primary eye care provider is to solidify our standing as part of primary care team via alignment with Medical Homes.  You should survey your primary care referral sources to see if they are an accredited Medical Home or are in process.  Maps and lists of accredited practices are available on the Ohio Department of Health website.  In addition, even though the promise of electronic interconnectedness has yet to be realized, participating in risk-sharing, outcomes-based reimbursement vehicles will be largely dependent on providers having EHRs with the ability to send and receive data.

Medicare Update for 2015

Medicare Update for 2015

Dr Brownlow

10 and 90 day global periods will be eliminated for minor surgical procedures in 2017 and for major surgical procedures in 2018.  Current 0, 10, and 90 day post op periods are still in effect for 2015!  Lots of ODs and staff have been asking me about the potential impact of all global periods going to 0 days.  Actually, I think it will be an advantage, as doctors providing post op care will no longer be limited by the meager CMS payments for post op periods, and will be submit claims for whatever visits and procedures are necessary during the post op period, just as they are during any other time they are caring for the patient.  Another interesting thing I’ve noticed about this issue…I’ve been getting more questions regarding these changes; though they won’t go into effect for two or three years; than I get on issues that should be of concern to doctors and staff currently and/or should have been of concern to docs and staff for years…Go figure!

Medicare Fee Schedule

The 2015 Medicare Fee Schedule has been published and it does include some changes, resulting in small net increases across the board for services ODs provide most commonly. Medicare’s fees are calculated based on relative values assigned for each service and the Conversion Factor, set by Congress each year.  The formula for calculating the fee for each services is Relative Value x Conversion Factor = Fee.  The conversion factor will be slightly lower at the beginning of 2015, though some of the relative values have increased, so the net impact will be very small.  However, a very large decrease in the conversion factor is slated to go into effect April 1, 2015, unless Congress acts prior to that date.  For those of you who have watched this strange scenario play out in previous years, this is no surprise.  My prediction?  Congress will act in the 11th hour to avoid the big cuts and leave the fee schedule pretty much as it is in 2014.

Act Now to Avoid PQRS Penalties in the Future

AOA has been successful in convincing CMS that small group practices (1-9 doctors) should not be penalized for PQRS issues, but should be eligible for the PQRS bonus payments.  2017 PQRS bonuses will be earned by PQRS participation in 2015, so gear up now to be sure you qualify.  You can continue to report PQRS measures on your Medicare claims, although AOA will be providing members with an easier way to accomplish that reporting, referred to as ‘registry reporting’, early in 2015.  Watch for more PQRS information from AOA in December.  If you decide to begin (or continue) to use the traditional method of reporting PQRS measures on each Medicare claim, you may do that as well.  There are lots of PQRS changes for 2015, so please refer to all of the information that has been created by the AOA Third Party Center. It’s all available to AOA members at  The major change for this year is that you must now report nine measures 50% of the time the related diagnoses appear on a claim.  Prior to his year you could have qualified by reporting only three PQRS measures 50% of the time the related diagnoses appear on a claim.  My advice at this point is to wait for AOA’s ‘Registry’ for PQRS reporting, which will make the process much more workable.

Medicare’s Impact on Optometry

CMS estimates that ODs provided services and were reimbursed over $1 billion in 2014 and predicts the total payments will rise in again for ODs in 2015.

Pretty amazing! And clear testimony of the value of your membership in the state association and AOA.  Without the hard work of organized optometry during the past thirty years and currently, we would not have been prepared to provide medical care to anyone, and we certainly would not have been granted full parity in Medicare, nor would we be providing full scope eye care services and being reimbursed by Medicare and other medical insurers today!

Charles B. Brownlow, OD, OS, OU

An Evolving Health Reform Landscape – Part 4 of 4

by Mark A. Ridenour of the Ridenour Group, Consultant to the Ohio Optometric Association

There are numerous other delivery and payment reform pilot projects currently happening or planned generally. The pilots are funded by state and/or federal grants.  As an illustrative example, note the following activity just in Ohio.  Innovation grants for coordinated pediatric care were awarded to University Hospitals of Cleveland and Nationwide Children’s (Columbus) earlier this year.  MetroHealth (Cleveland) was granted a waiver to deliver Medicaid-like benefits to a local uninsured population, although this project has yet to launch.  Governor Kasich submitted a grant application for a federal State Innovation Model (SIM) to extend Medical Homes and facilitate payment reform via episode-based modules (e.g. a single payment for the care and rehabilitation of knee replacement).

Each of these delivery and payment system changes (Medical Homes, ACOs, bundled payment models, and other initiatives) modifies the flow of patients and/or funds. If Optometry is not actively engaged and promoting its value, the results are likely to mean less of both.  The good news is that, as the primary eye care provider, your services align with the general shift of investment to primary/preventive care.  An efficient exchange of data inter-professionally will be key to each of these initiatives.  Therefore, your EHR capabilities and willingness to participate should provide the necessary advantage to avoid exclusion.

At least in the interim, and perhaps for the longer term, there will be variation in how these shifts manifest locally.   In Ohio, the Ohio Optometric Association has identified key relationships for each of these pilots and has engaged administration and key optometrists in the planning and design wherever possible.   While the scope of this is very broad, impacts are felt at a local level.  Be cognizant of change within your inter-professional community and, as always, contact Ohio Optometric Association for support.

“An Evolving Health Reform Landscape” is a four-part series.

An Evolving Health Reform Landscape – Part 3 of 4

by Mark A. Ridenour of the Ridenour Group, Consultant to the Ohio Optometric Association

Accountable Care Organizations (ACOs) are health systems, hospital or physician-led, which are charged with the management of the health of a defined population.  Medicare has led with various models, the most popular of which is the Medicare Shared Savings Program (MSSP). Medicare will continue to pay individual providers and suppliers for specific items and services as it currently does under the Fee-For-Service payment systems. Should the ACO achieve lower costs and better quality outcomes than projected, Medicare will share the financial savings with the ACO, which then shares it with its providers.

The Advance Payment Model is designed for physician-based and rural providers who have come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. Selected participants will receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure.

The Pioneer ACO Model is designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the MSSP.  A minimum of 15,000 Medicare beneficiaries must be managed in this model versus the  5,000 minimum for the MSSP.

Each of these models will eventually move to a population-based payment model. Population-based payment is a per-beneficiary-per-month payment amount intended to replace some or all of the ACO’s fee-for-service (FFS) payments with a prospective monthly payment.  Recent CMS notices have stated that 154 organizations now participate in all Medicare ACO programs.  Since there is no accreditation, there is no accounting of private ACOs however it is known that most major hospital systems and large physician organizations have these in development with plans to offer to multiple payers.

“An Evolving Health Reform Landscape” is a four-part series.

An Evolving Health Reform Landscape – Part 2 of 4

by Mark A. Ridenour of the Ridenour Group, Consultant to the Ohio Optometric Association

Primary care practices are moving to a Medical Home model. The medical home aims to replace the current episodic sick care model with one that employs a team of health care providers, led by the physician, to engage the patient in an ongoing relationship toward optimizing personal health and coordinating all care.  Access is enhanced by open scheduling, expanded hours, and communication options other than face-to-face.  The most common term used is the Patient-Centered Medical Home (PCMH) which is accredited by NCQA and others.  Accreditation is a requirement for most insurers to enable enhanced reimbursement.

The transformation of Primary Care practices to PCMH has increased exponentially across the country with robust development where additional state and federal level support is present.  There are now nearly 200 accredited PCMHs across Ohio, for example, with others in the pipeline aided by state funds targeted to assist practices in making this transformation.  Ohio has been recognized as a leader in PCMH with the Cincinnati/Dayton region selected as one of seven in the country where Medicare, under the CMS Innovation Center’s  Comprehensive Primary Care Initiative (CPCi), is joining nine other payers in support of a four year pilot expected to yield $15M from Medicare for 75 practices over the next four years.  Another government initiated model, Health Homes, is a Medicaid version focused on mental health and those with multiple chronic conditions.

“An Evolving Health Reform Landscape” is a four-part series.

An Evolving Health Reform Landscape – Part 1 of 4

by Mark A. Ridenour of the Ridenour Group, Consultant to the Ohio Optometric Association

Change in delivery and payment systems within healthcare today seems to be ever-present and accelerating.  Some of this pace is dictated by deadlines within the Affordable Care Act (ACA), but much is fueled by a broad recognition of the urgent need for fundamental improvements in how health care is accessed, delivered and financed.  The results to date speak for themselves.  As all players strive to position themselves for tomorrow’s environment, multiple transformations can make it all very confusing.  This blog series will identify the current status of several impactful transitions now underway and why you should care.

Most modifications in healthcare delivery systems are associated with changes in reimbursement.  A common phrase used to describe the shift in payment systems is “from volume to value”.  This speaks to the efforts to move from rewarding providers for the number of services performed via a typical fee-for-service form of payment, toward one which rewards outcomes.  This can take many forms including pay-for-performance bonuses based on patient quality markers, to the avoidance of emergency room visits in a population, to a more direct shift of financial risk to the provider via bundled payments or capitation.  A generalization of this trend would be a greater investment in primary/preventive care with the expectation of improved health, and the avoidance or delay of some of the costs of illness care.  These types of payment system changes are embedded in all the delivery system transformations taking place across the country.

“An Evolving Health Reform Landscape” is a four-part series.