Investing In SLT
Patient demand and favorable reimbursement guidelines contribute to the appeal of this IOP-lowering therapy.

Selective laser trabeculoplasty (SLT) has reduced IOP in many primary open-angle glaucoma patients and selected secondary glaucoma patients. But it takes more than clinical success to justify adding a new piece of capital equipment, such as the Selecta II Glaucoma Laser System, to your practice.

A successful investment in SLT requires facilitating a timetable for reasonable return on investment, ensuring effective documentation to realize timely reimbursement and seamlessly integrating this procedure into your practice.

But the first step in building your SLT practice is acquiring the proper equipment.

Buying an SLT system

To some, the initial capital outlay for an SLT laser can seem extravagant until they realize the financial opportunities they're missing by not having this equipment.

"I thought $60,000 to $80,000 seemed a little high, until I heard the 3-year outcomes reported at an American Glaucoma Society meeting," says Monte Dirks, M.D., of Blackhills Regional Eye Institute in Rapid City, S.D. "When those data came out, I decided I didn't want to be the last glaucoma specialist to have this equipment. I calculated that the laser would pay for itself in a couple of years if I performed 100 SLTs a year, but we've had so much success with it that I overestimated the time it would take to recover my costs."

Third-party private insurers reimburse about $1,800 for SLT, according to Dr. Dirks. "Our profession isn't all about money but it's difficult to overlook how profitable this procedure is in terms of time spent and income received. Another benefit of adopting SLT is that I've been able to offer pro bono treatment to uninsured patients because we're doing so well on the third party-insured patients," he adds.

One clinician embraced SLT technology as a valuable investment opportunity. "Physicians will put money in the stock market and in all sorts of wild and wooly investments, when the best investment we can make is in our own practice," says James B. Wise, M.D., of Glaucoma and Laser Surgery Associates in Oklahoma City. "The obvious benefits of buying an SLT laser are that it's tax deductible and that having it improves the quality of your practice."

Although SLT may be used less in a primarily tertiary-care practice compared to a comprehensive ophthalmology practice, Boston glaucoma specialist Mark A. Latina, M.D., realized he could recoup his return on investment in just 1 year by performing 10 SLTs per month. In some instances, clinicians can receive a facility fee for SLT.

"Technically, our practice is a limited liability partnership separate from the surgicenter, so we qualify for a facility fee when we perform planned SLT blocks in the surgicenter," says Dr. Dirks. "But the device also is portable, so I can set up the laser in an exam room to treat patients who would have difficulty returning for a scheduled SLT," he says.

Robert J. Noecker, M.D., who practices in an academic setting at the University of Pittsburgh, points out how easy it is to justify purchasing an SLT laser.

"The pro formas are easy to recoup, and the numbers speak for themselves," he says. "University administrations usually strive to break even. So the answer to 'should we buy this equipment?' is easy, even though most university practices don't receive facility fees."

Building an SLT Patient Base

Once you have your SLT equipment in place, your next step should be making patients aware you're off- ering this procedure. Most of the patients referred to Dr. Dirks' practice hear about SLT from former satisfied patients.

"In a small, tight-knit community like Rapid City, S.D., word-of-mouth spreads quickly. People actually call and say, 'I want that new cold laser so I can get rid of my drops,'" he says. Dr. Dirks also ran an advertisement highlighting the case history of a particularly happy patient who stopped using three medications after a complete 360° SLT. "This testimonial generated quite a few phone calls," says Dr. Dirks.

Brian A. Francis, M.D., of Doheny Eye Institute at the University of Southern California Keck School of Medicine in Los Angeles, found his SLT patients within his practice.

"Some of our patients came to us from referring physicians who know we have an SLT laser, but we haven't done any direct advertising. Most of our SLT patients have come from our own practice," he says.

Establishing SLT Schedules

Adding a new procedure to your office routine can be disruptive, so it's important to revise your schedule to accommodate new SLT candidates. Depending on the volume of procedures, some surgeons schedule all their SLTs for a single day each week or month, block off a portion of their regular practice day or intersperse SLT procedures throughout their regular schedule.

Dr. Dirks performs all his SLTs during a 3-hour period one afternoon each week. "I have two technicians working with me, and we can do 18 to 20 SLT procedures during that time," he says. "One technician prepares the patients for SLT and the other assists with the procedure and oversees post-op checks. This system flows very well, and we can do six to eight cases an hour without falling behind schedule," he adds.

Clinicians who perform significantly fewer SLTs often schedule procedures before normal clinic hours, a strategy followed by Ronald L. Gross, M.D., professor of ophthalmology at Baylor College of Medicine Cullen Eye Institute in Houston.

"Usually, I can complete one or two SLTs in the 15 minutes before my regular patients arrive," says Dr. Gross. "The technicians work them up 15 minutes before the procedure, then while I'm doing the SLTs, the technicians are getting started with the clinic patients," he explains. Dr. Gross checks his SLT patients' IOPs 1 hour after surgery. "We really didn't make too many changes to our schedule to accommodate SLT," he says.

Because he has a dedicated laser room housing his SLT, YAG and argon lasers, Dr. Wise's SLT scheduling approach is very flexible. "If I determine my patient needs SLT during the course of my examination, I send him down the hall. After I treat him, I go back to see the rest of my patients," he says.

Dr. Latina prefers to schedule back-to-back SLT patients on a single day. However, he'll make an exception for any patient who lives far enough away from his office that traveling back for the procedure would be a hardship.

"Otherwise, I like to do all my SLTs on a separate day because interspersing this procedure among regular patient visits can be disruptive. Dedicated SLT days help us stay on schedule," he says.

Integrating SLT patients into his normal clinic patient flow works well for Dr. Noecker. "We keep a freestanding SLT laser in one of our exam rooms. When we decide a patient needs SLT, we just roll the machine up to the chair," he says.

Clearly, patients appreciate the positive medical results of SLT, but this procedure also offers financial rewards to patients and clinicians alike.

"Medicare doesn't provide substantial support for prescription glaucoma drugs, but it will pay for SLT, ultimately saving patients a lot of money," says Dr. Dirks. "Eliminating two medications for patients who have no prescription drug coverage saves them $100 or more a month, which adds up to well more than $1,000 a year," he says.

Even if Medicare covers only 80% of the SLT cost, the 20% for which the patient is responsible is roughly equivalent to the cost of a single bottle of eye drops, says Dr. Wise. "I tell my patients this so they understand they'll absorb the cost rather quickly," he says.

Medicare reimbursement rates also make SLT an attractive procedure for clinicians. (See "Current SLT Reimbursement Information.")

"Reimbursement for SLT is very generous, considering the procedure usually takes 5 minutes to perform," says Dr. Dirks. "Medicare will pay more for filtration surgery but this procedure requires at least 1 hour to complete, including travel time to and from the OR. I'd rather do SLT," he says.

Ophthalmologists who are concerned that increased laser trabeculoplasty CPT 65855 usage could trigger a private insurance or Medicare audit shouldn't worry as long as they document the procedure appropriately.

"Specify that the patient has glaucoma, what category the patient falls into -- new diagnosis, controlled on medications or uncontrolled on medications -- and the reason for using a laser," says Dr. Francis.

"Document a newly diagnosed patient's inability to use medications or his preference to not use medications. If the patient is controlled on medications, document his desire to reduce medications or his problems with cost, compliance or tolerability. For a patient who's uncontrolled on medications, explain that incisional surgery is an option and was discussed with the patient," he adds.

Dr. Latina recommends documenting that alternative therapies include medications and laser procedures.

"Poor compliance, difficulty using medications, and medication costs, as well as uncontrolled IOP and disc damage, all are good reasons to perform SLT," he says. "Providing adequate documentation should satisfy insurance coverage concerns."

And finally, Dr. Gross points out that data from peer-reviewed literature supports using laser trabeculoplasty at any stage of glaucoma treatment.

Solid Investment

The medical and financial return on investment for SLT is excellent. Patients appreciate the long-term efficacy of this noninvasive procedure, as well as the money they save by reducing or eliminating their dependence on IOP-lowering medications.

Physicians derive satisfaction from preventing glaucoma progression with a procedure that doesn't disrupt other aspects of their practices. SLT definitely is poised to become the new standard in glaucoma therapy.