Let’s Be Friends: 5 Steps for Successful Co-management

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Co-management…what does that word mean to you?

Does it represent a way to form a relationship with a surgeon that will help you grow your practice and strengthen the bonds with your patients? Or is it a daily frustration that comes as a result of unclear expectations between parties?

If you happen to lean more toward the latter definition, don’t worry.

Co-management between ODs and MDs can actually be a very healthy and seamless process, if you just follow these 5 steps:

1. Educate yourself thoroughly on the surgeons in your area. 

While it is true that some towns may only have one option when it comes to cataract, retina, or other specialty referrals, if at all possible, you should make a point to explore your options regarding surgeons. Sometimes this may mean looking slightly outside your immediate area, but if the results are finding a MD who is willing to fully work with you in the care of your patients, trust me, it’s worth it.

Some points that should be considered when selecting your preferred referral surgeon include:

  • How do the surgeon’s results compare to his or her competitors? Do your research, ask your colleagues, and make sure you are comfortable with the level of outcomes that a surgeon has before putting your endorsement behind him/her. Your patients trust you, and while you can’t force them to go to any one MD, you can recommend whichever surgeon you think is best. Make sure it’s an educated recommendation.
  • Is this surgeon optometry-friendly? Finding a MD that is optometry-friendly will make establishing a close working relationship much easier. Again, talk to your fellow optometrists. This will give you great insight into how easy or difficult someone is to co-manage with.
  • Is the surgeon’s office easy to communicate with? You want to make sure that you find someone who will not only communicate regarding his or her exams and surgeries, but also someone who will listen and be reachable to help if you have an outcome or problem that makes you uncomfortable.

2. Know your surgeon’s protocols.

Each and every surgeon is different, particularly in post op schedules and medications. Some cataract surgeons may prefer to have a same-day post op, while others will demand a one day. Some will want a patient dilated at the one week post op visit; others prefer dilation at one month.

Even greater differences lie in post op medications. Depending on the surgery, there may be a combination of NSAIDs, steroids, antibiotics, or other topical meds prescribed, or the surgeon may have administered all meds during surgery. In some cases, post op meds simply are not required.

Once you have selected your preferred surgeon(s) with whom you’d like to co-manage, it is absolutely essential to gain an understanding of the expected post op schedule, medications commonly used, and frequency of dosing for each medication. Typically, the MDs office will be able to provide your practice with paperwork outlining all of this. In addition to the preferred medications used, it is also helpful to find out what medications the surgeon will substitute should the patient run into problems acquiring their drops.

For Example: Let’s assume a cataract surgeon prefers that his patients use Vigamox QID x 1 week in the operative eye. Many patients today have insurance plans that will not cover Vigamox. Therefore, the MD’s office may substitute that antibiotic for a combination of Polytrim and Tobrex.

Having a working knowledge of the common substitutions that may be made for your patients will help you avoid curve balls in your chair.

3. Find out what post operative findings your surgeon considers normal vs. abnormal.

A great example of this can be found in cataract surgery.

There are multiple techniques that a cataract surgeon may employ, and each can result in a different corneal presentation in the days following the procedure. If the surgeon uses a technique that directs little energy toward the cornea, you would expect a relatively unremarkable endothelium. However, if he or she prefers to move the lens toward the cornea to work, more energy is concentrated within the anterior chamber and therefore, you may see quite a bit of endothelial haze. Surgeon 1 in this example may not consider endothelial haze as normal, while surgeon 2 would.

It is important to remember that every surgeon is different, and while results may eventually end up very similar at one month or three months post-surgery, the process to get to that end result may look very different from MD to MD. Especially early in the establishment of a co-management relationship, it is integral to communicate with the surgeon or the surgeon’s office to find out what his or her eyes typically look like in each post op. Make sure to find out the surgeon’s expectations regarding corneal appearance, IOP, visual outcome, and retinal findings.

While knowing what to expect will allow you more comfort in managing your post operative patients, it is equally as necessary to know what your surgeon considers out of the norm and how he or she would like you to handle those situations. Some things may be as easy as adding another topical medication; for example, a surgeon may ask that you add an IOP lowering med to any post op patient with intraocular pressure over 25. Other findings may require an examination by the surgeon himself.

Good lines of communication with the surgeon’s office will be key in acquiring this information.

If at all possible, shadowing the surgeon early in a co-management arrangement is a great way to establish a baseline of post operative expectations, as well as form a stronger working relationship between yourself and the MD. 

4. Establish a contact list/open lines of communication.

In order for co-management to fully and smoothly work, the OD must establish reliable line(s) of communication with the surgeon and his or her office.

You should be aware of whom you office should contact to schedule your patients, whom to call at the surgeon’s office if there is a problem of any kind, whom to send paperwork to both prior to the referral and during the post op care, and whom will be sending communications to your office regarding the exam and surgical report.

You should also be aware of how to contact the surgeon directly if necessary. If the relationship is a good one, these contacts should not be hard to establish.

5. Make sure you understand how to correctly bill for your services.

In a co-management setting, both the surgeon and the OD performing the post operative care are entitled to reimbursement.

The surgeon will attach the -54 modifier to the surgical code to relay to the patient’s insurance company that surgery was performed and post op care will be with a different provider. The OD then bills the same surgical CPT code as the surgeon’s office with -55 modifier attached. This will alert the insurer that you are providing post op care only for this procedure. In addition, the OD should also use code 99024, post op, with the diagnosis associated with the surgery to show that a post op exam was performed.

Remember, most procedures that will be co-managed will have a 90 day global period. This means that any visits related to the procedure that occur within the 90 days following surgery are covered and no copay should be collected.

It is also important to recognize that some procedures are considered related, and therefore, result in a combined post op period if the second procedure is performed within the global period of the first.

An example of this would be a patient who had cataract surgery and is sent back to the surgeon for a YAG 1 month later. The capsulotomy is considered a related procedure to the cataract extraction by insurance companies; because the YAG was performed within the 90 days of the cataract surgery, the initial 90 day global period remains in effect, and you are unable to bill for two separate post ops. The global period for both procedures ends 90 days after the cataract surgery, not 90 days after the YAG.

When done correctly, co-management can be a true practice builder. It helps you strengthen your clinical skills, build the trust of your patients, and establish strong working relationships with other eye care professionals close to your practice. Through working together, the patient benefits and is sure to receive the best care available…which should always be our ultimate goal.

Note: As the center director of a fully referral-based, co-management practice, I deal with these relationships every day. I would love to help you as you establish your co-management network, so please don’t hesitate to let me know any questions you may have.

About Patricia Fulmer O.D.

Patricia Fulmer O.D.
Patricia is a 2012 graduate of The University of Alabama at Birmingham School of Optometry and former AOSA National Liaison to the AAO. After graduation, she moved to Amarillo, TX, to complete her residency in Ocular Disease and Primary Care at the Thomas E. Creek VA Hospital. Patricia is the current Center Director for VisionAmerica of Huntsville, a co-management practice specializing in secondary and tertiary care, cataract surgery, strabismus, and oculoplastics in Huntsville, AL. She recently earned her Fellowship in the American Academy of Optometry at the 2015 meeting in New Orleans. In her free time, she enjoys traveling, attending concerts, art, and Alabama football.

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