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TIPS AND NEWS YOU CAN USE

Debate Grows Over Limits on Nurse Anesthetists
AAO and ASCRS Favor Physician Supervision.

A last-minute ruling by the outgoing Clinton Administration eliminating the need for physician supervision of nurse anesthetists in Medicare and Medicaid cases will be reversed if Republican lawmakers and numerous surgical and medical associations have their way.

The ruling would allow state-licensed nurse anesthetists to be reimbursed directly by Medicare.

Republican lawmakers responded to the Jan. 18 HCFA ruling by introducing bills in the House and Senate to restore physician supervision for any procedure in which any type of anesthetic is administered.

On Feb. 1, a total of 93 medical and surgical associations, including the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS), joined in sending a letter to Tommy Thompson, U.S. Secretary of Health and Human Services (HHS), expressing concern about the Clinton Administration's action and asking that the ruling be rescinded.

"Nurse anesthetists aren't medical doctors. Every patient that goes under anesthesia is at some level of risk," says Sandra Remey, communications manager for the Governmental Affairs Division of the AAO. "Whoever administers the drug must know how to immediately identify a problem and be able to react in the patient's best interests in all cases."

In the letter, the medical organizations said they were "deeply troubled" by the assumption that the elimination of physician supervision can be presumed to be safe without scientific proof.

Dave Herbert, director of Governmental Relations for the American Association of Nurse Anesthetists (AANA), said efforts to rescind the Jan. 18 ruling were attempts by "organized medicine in general and anesthesiologists in particular to protect their turf."

The Bush Administration has delayed implementation of the Jan. 18 ruling, pending a review by HHS.

Device Gathers Eye Stem Cells
Researchers See Promise.

Researchers at the University of California Irvine have developed a device designed to make it easier for surgeons to harvest eye stem cells to correct blindness caused by disease or chemical damage.

Eye stem cells are used in a surgical procedure called limbal stem cell transplantation, which involves transplant-
ing donor stem cells onto the cornea of a patient to restore vision. Patients who undergo this procedure either have chemical damage to their eyes or suffer from diseases such as Stevens-Johnson Syndrome, a rare disorder that causes blindness.

But harvesting stem cells for the procedure is a difficult surgical process, and the success rate for limbal stem cell transplantation is still low.

"Stem cell transplants have corrected blindness in many patients, but are still considered a last-ditch effort to save the patient's eyes," says Roy Chuck, M.D., assistant professor of ophthalmology at UC Irvine.

It's hoped that UC Irvine's new stem cell harvester device can advance the effectiveness of limbal stem cell transplantation by providing surgeons with the large numbers of stem cells needed to make the procedure successful. The device is a modified microkeratome designed to cut off an entire cornea, allowing for the removal of the limbus, which contains the stem cells.

Results of preliminary studies are promising, and human trials involving up to 20 patients are expected to begin later this year.

JCAHO Offers Accreditation for Ophthalmologists
New Programs Cover Office-Based Surgery, ASCs and Laser Vision Correction Facilities.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which sets widely accepted standards for evaluating the performance of hospitals, long-term care facilities, home care agencies, clinical laboratories and other healthcare organizations, is now offering two new accreditation programs that encompass ophthalmology.

Ophthalmologists who perform operations or invasive procedures in an office setting may now apply for JCAHO accreditation under the new Office-Based Surgery (OBS) program. Free-standing ambulatory surgery centers (ASCs) and laser vision correction facilities may qualify under the ambulatory accreditation program.

The Laser Eye Center, based in Glendora, Calif., recently became the first free-standing laser vision correction facility in the United States to receive JCAHO accreditation.

"We sought accreditation to deliver a message of quality and professionalism in a market cluttered by providers of questionable reputation," says Antoine Garabet, M.D., chief of staff of the Laser Eye Center. "Accreditation from JCAHO affirms our commitment to providing our patients with the highest quality eye care available."

Ophthalmology practices seeking accreditation in the OBS category must pay a $3,975 fee to go through the application and site visit process. Free-standing facilities and ASCs pay higher fees, based on their size. If you have an interest in JCAHO accreditation, you can e-mail Mike Dye at mdye@jcaho.org.

LASIK Patients Get Lost in Merger Shuffle
Some Centers Closed; Doctor Walkouts Caused Temporary Shutdowns at Others.

The long-awaited consolidation of the laser vision correction industry has begun, inconveniencing hundreds of former Lasik Vision patients.

While four Lasik Vision refractive surgery centers were permanently closed as a direct result of the recent merger with Icon Laser Eye Centers Inc., almost all Lasik Vision centers experienced temporary shutdowns as doctors walked out over back-pay issues. Icon says those issues have largely been resolved.

Icon officially took over Lasik Vision Corporation on March 1 and moved quickly to close Lasik Vision refractive surgery centers in Honolulu, Toronto, Vancouver and Windsor, Ontario.

"These are markets in which we had Icon and Lasik Vision centers in close proximity," said Joe Krupa, Icon spokesperson. "It required some patient rescheduling. There have been some customer complaints, especially in Honolulu. It's part of the growing pains associated with combining two large companies."

About 170 former Lasik Vision patients in Honolulu were directed to an Icon-affiliated center in Honolulu, but the Honolulu Star-Bulletin reported that some customers complained about having difficulty in arranging appointments or obtaining refunds.

"All commitments to patients made by Lasik Vision will be fully honored and no deposits will be lost," Krupa said.

Krupa also told Ophthalmology Management that Icon's goal is to stabilize its basic price point for LASIK at $750 an eye.

CIBA Lenses Get OK for Allergy Claim
FDA Reviewed Dailies Data.

There's good news for many eye allergy sufferers who already wear -- or would like to wear -- contact lenses.

CIBA Vision can now claim that its Focus Dailies daily disposable contact lenses can benefit wearers who have seasonal allergic conjunctivitis (SAC).

"Twenty to 30% of the U.S. population have allergic eye diseases, and about 50% of allergic eye disease is SAC," said Richard Weisbarth, O.D., CIBA Vision's executive director of Professional Services for North America. "Eyecare professionals can now recommend Focus Dailies to their patients who suffer from SAC, with the expectation that many of them will have more successful contact lens wear."

Dr. Weisbarth said the FDA's action will impact how CIBA Vision labels and promotes Focus Dailies.

Medical Thriller Has Refractive Surgery Theme
"I'm Not Ready for the Book Signing Tour Just Yet," Ophthalmologist-Author Says.

Back in the early 1990s, Douglas F. Greer, M.D., who practices ophthalmology in Wash-ington, D.C., decided he wanted to write a novel about high-tech medicine and the bad things that can happen when the medical/industrial complex puts money ahead of patient safety.

Douglas F. Greer, M.D.

"My thinking was very broad at the time," says Dr. Greer, who wrote class shows during his undergraduate days at Princeton and in medical school at the Columbia College of Physicians and Surgeons in New York City. "I wanted to cover HMOs, malpractice and the larger medical realm. And the book would have a ticking time-bomb climax."

But somewhere along the line Dr. Greer remembered the advice given to all fledgling novelists: Write about what you know.

And that was the genesis of his recently published medical thriller, Blind Ambition, which revolves around a new type of laser treatment for myopia, a hot new stock offering, a mysterious blind vagrant and murder. A New York City ophthalmologist and his medical student girlfriend get involved in trying to tie together the pieces of this mystery.

"It's fictitious, but very timely," says Dr. Greer. "There's great interest in laser vision correction right now.

Dr. Greer, who's been in practice more than 25 years, doesn't perform refractive surgery. He's a general ophthalmologist, with an emphasis on cataract surgery and corneal transplants.

"I'd characterize myself as conservative in regard to the practice of medicine," says the doctor. "I'm still not sure about the complications and long-term effects of LASIK, but I do refer out patients who have a truly compelling need to have it done."

Blind Ambition has won a rave review from Robin Cook, the king of medical techno-thrillers.

"People who've read the book tell me they couldn't put it down," says Dr. Greer, "which makes me feel good. I know I worked hard to educate readers a bit about refractive errors and to make the characters seem like real people. But I'm not ready for the book signing tour just yet."

Douglas F. Greer, M.D.

Sunglass Hut Brand Is Offered to Ophthalmologists
Is There A "Sunglass Hut Corner" in Your Future?

When the Italian-based eyewear maker Luxottica Group recently announced an agreement to purchase Sunglass Hut International Inc. for $653 million, it was more than a case of Luxottica picking up almost 2,000 retail outlets worldwide. The move also signaled an initiative to expand the Sunglass Hut presence to ophthalmologist-owned optical shops.

"We don't intend to limit the Sunglass Hut brand to just retail stores," says Henry Sand, vice president of sales

Sand says that once the Sunglass Hut purchase is finalized, Luxottica will begin pilot programs with a limited number of ophthalmology practices to determine which sales concept is most effective in generating sunglass purchases.

"We want to see what kind of feedback we get from these test programs. Then we can tailor the concept before rolling it out to a larger number of ophthalmology practices," says Sand.

Glaucoma Drugs Receive Approval
Lumigan, Travatan and Alphagan P Now Available.

Two new drugs whose purpose is to lower elevated intraocular pressure (IOP) associated with glaucoma were approved by the FDA on the same day in March, while a variation of an existing glaucoma treatment received approval a few days later.

The approvals are intended to provide more alternatives for reducing IOP in patients who are either intolerant of other IOP-lowering medications, or who have had insufficient responses to other drugs.

The two new drugs approved are bimatoprost ophthalmic solution 0.03% (Lumigan), developed by Allergan, and travoprost ophthalmic solution 0.004% (Travatan), manufactured by Alcon. Both drugs are indicated for the reduction of elevated IOP in patients with open-angle glaucoma or ocular hypertension.

Alphagan P, another IOP-reducing drug from Allergan, was also approved. It's a new formulation containing the alpha2 agonist brimonidine tartrate, the same active ingredient in Allergan's Alphagan.

Allergan says Lumigan is the first synthetic prostamide analog developed from an original synthesized molecule.

Alcon's Travatan is the first glaucoma drug to demonstrate greater effectiveness in black patients, according to the company.

"Glaucoma is far more prevalent and serious in patients of African descent," says Jess Whitson, M.D., associate professor of ophthalmology at the University of Texas Southwestern Medical School in Dallas. "Patients of African descent are four times more likely to suffer from glaucoma and far more likely to go blind from this disease."

REFRACTIVE SURGERY UPDATE

• LadarVision chosen. NovaMed Eyecare Inc. and TLC Laser Eye Centers have entered into separate, multiyear technology agreements with Alcon. Both Novamed and TLC plan to use Alcon's LadarVision system as their primary refractive surgery platform in North America.
• Hyperopia, astigmatism. LaserSight has filed an application with the FDA requesting approval to use its LaserScan excimer laser system to perform LASIK treatment of hyperopia, hyperopic astigmatism and mixed astigmatism.
• Patent confirmed. After a more than 2-year review, the U.S. Patent and Trademark Office has confirmed LaserSight's broad patent rights to precision beam microspot scanning laser refractive surgery under the company's so-called "679" patent. The Patent Office also issued 68 additional claims under the patent to encompass the overall breadth of the technology.
• Procedures increase. TLC Laser Eye Centers Inc. reported that more than 33,500 laser procedures were performed at company centers in the quarter that ended Feb.28. The number was 24% higher than the preceding quarter. The company said financial results for the most recent quarter would be "substantially better" than the consensus estimate of a $0.13 loss and might be close to break-even before restructuring charges.
• Thin air effects. New research shows that the thin air of high-altitude environments can blur surgically corrected vision. Mountain climbers, skiers, pilots and others who have undergone LASIK for myopia may experience a return of nearsightedness in these low-oxygen environments.
• Procedure volume. Laser Vision Centers, Inc. announced that U.S. refractive surgery procedures for the 3 months ended Jan. 31 totaled 36,335, a 37% increase over the same period a year ago.

IN THE NEWS

• AIDS eye drug. An FDA advisory panel has unanimously recommended the approval of valganciclovir for treatment of cytomegalovirus retinitis, a sight-threatening viral infection that affects up to 40% of late-stage AIDS patients. Valganciclovir, made by Roche, is the oral form of the intravenous drug ganciclovir (Cytovene IV).
• VisionWeb investment. Allergan has joined Essilor of America and Johnson & Johnson Vision Care as an equity investor in VisionWeb, a new online network and business exchange for the eyecare industry.
• Acquisition. Italian eyewear maker Luxottica Group has agreed to purchase specialty retailer Sunglass Hut International Inc. for $462 million and the assumption of $191 million in debt. Sunglass Hut currently operates 1,962 retail outlets worldwide.
• B&L settlement. As part of a nationwide settlement, Bausch & Lomb will provide eligible U.S. consumers with "benefits" packages worth more than $120 each, including rebates on contact lenses and eye examinations, and free samples and discounts on B&L products. The $17.5 million settlement carries no admission of wrongdoing. It stems from a 1994 lawsuit charging that several contact lens makers conspired with optometrists and the American Optometric Association to limit the distribution of their contact lenses.
• Patent war. Allergan Inc. has filed a lawsuit challenging the validity of two Pharmacia Corp. patents used in the manufacture of Pharmacia's market-leading glaucoma treatment, latanoprost ophthalmic solution (Xalatan). The suit came after Pharmacia threatened to block the launch of Allergan's recently approved glaucoma treatment, bimatoprost ophthalmic solution 0.03% (Lumigan).
• Resignations. In an effort to cut costs, KeraVision chairman and CEO Thomas Loarie and president and COO John Galantic have resigned. KeraVision has made dramatic staff cuts recently so it can use its remaining cash to fund clinical trials involving potential new applications for Intacs prescription inserts.
• System selected. Kaiser Permanente, the country's largest not-for-profit HMO, has selected Alcon's Series 20000 Legacy phacoemulsification system for use in cataract surgery. The choice was made after an evaluation by Kaiser.

Hot Topics, Expert Speakers

Join Ophthalmology Management at one or more of these free educational seminars during this year's ASCRS annual meeting.

STRATEGIES FOR IMPROVING SURGICAL OUTCOMES

Alan B. Aker, M.D., F.A.C.S., Ophthalmology Management Chief Medical Editor, Moderator
R. Bruce Wallace III, M.D. "Meeting the Demand for IOL Precision with Optical Coherence Biometry"
Marc G. Odrich, M.D. "Generating Successful Outcomes Through Ablation-Planning Software"
Warren E. Hill, M.D., F.A.C.S. "The Role of Wavefront Sensing in the Clinical and Refractive Practice"

• When: Saturday, April 28 from 6 p.m. to 8 p.m.
• Where: Horton Grand Hotel, Regal A, 311 Island Ave., San Diego

Sponsored by Zeiss Humphrey Systems.
A light dinner will be served.

USE OF THE RETINA TOMOGRAPH IN CLINICAL PRACTICE

Jorge Alvarado, M.D. "Clinical Use of the Retina Tomograph to Aid in Differential Diagnosis"
John Flanagan, Ph.D. "Understanding the Theory of Retina Tomograph Operation and Use in Detecting Glaucomatous Progression"
Kevin Corcoran, COE, CPC. "Practice Management Considerations"

• When: Saturday, April 28 at 6 a.m.
• Where: Horton Grand Hotel, Regal C, 311 Island Ave., San Diego

Sponsored by Heidelberg Engineering.
A full breakfast will be served.

TAX STRATEGIES FOR 2001 AND BEYOND

Thomas E. Nelson, J.D., and Michael J. Hardesty. "Reduce Your Taxes by 50% or More ... Retire Young ... Leverage Your Money ... Insulate Your Wealth"

• When: Sunday, April 29 from 6:15 a.m. to 7 a.m.
• Where: Horton Grand Hotel, Regal A, 311 Island Ave., San Diego

Sponsored by Innovative Business Consulting.
A full breakfast will be served.

To obtain more information or to register for any of the seminars, call (877) 400-1692. Space is limited!

Coding: TIP

Heather B. Freeland, director of Coding and Compliance, Rose and Associates, healthcare consultants, Duncanville, Texas, provides the following helpful tips on reimbursement for glaucoma-related procedures. For more tips on cost-effective glaucoma care, see "You Can Provide Cost-Effective Glaucoma Care".

Some ophthalmologists aren't getting paid for the work they perform because they don't know the correct coding for specific procedures, or they aren't doing the procedures in accordance with the requirements of a specific code Here are a few examples:

• 66170, trabecelectomy without previous surgery. You must document on the clinical chart or operative report that there was no previous surgery or anterior segment scarring. If the procedure included antifibrotic injections of 5-FU or Mitomycin, you can bill these injections under a global fee, but you can't bill them separately.
• 66172, trabeculectomy with previous surgery. You must document that there was previous surgery to the eye that resulted in anterior segment scarring. You won't be paid if the scarring is retinal. Also, if you are redoing your own work within 90 days, you'll need to file a 78 modifier under code 66172. Again, as with code 66170, you can't bill Mitomycin separately.
• Post-trabeculectomy procedures. If you perform paracentesis under code 65805 or needle a bleb under code 66250, you will only be reimbursed if the procedure is performed in a dedicated surgical suite or ASC. Performing either of these procedures in the lane will result in denial of payment. If you put the patient in your office surgical suite, you can perform these procedures and obtain reimbursement. If you perform either of these procedures in an ASC, the ASC receives a facility fee and you get a reduced "in-facility" fee. Append a 78 modifier. This indicates a "return to OR."