At Press Time

Eye MDs Lack Necessary Coding Training

Increase in audits puts them in jeopardy.

■ Many ophthalmologists leave all coding decisions to staff members, apparently not realizing that it is the physician who is personally and ultimately responsible for the accuracy of claims for reimbursement. As coding expert Riva Lee Asbell has emphasized in a recent series of articles in Ophthalmology Management, if an audit uncovers a pattern of discrepancies in reimbursement, it is the physician who pays the fine or goes to jail.

Given an environment of greatly increased audit activity, a presentation made at ARVO by researchers at Boston Medical Center is particularly timely.

Prompted by reports that residents across different specialties have noted that “training in coding compliance, reimbursement and practice management is underemphasized and sometimes completely overlooked during their training,” the researchers' aim was to assess ophthalmology residents' knowledge level and training in these areas.

To that end, ophthalmology residents across the US were invited to complete a 22-question online survey. Data were gathered using anonymous, self-administered, standardized online questionnaires, which were subsequently analyzed with spreadsheet software.

Fifty-five residents completed the survey, with 15 resident programs represented in total. Sixty-five percent of responders said they have received at least one lecture on coding during residency vs 35% who had no instruction.

Of those respondents who received at least one lecture, none had more than six hours of lectures dedicated to the business aspect of ophthalmology. Over 80% of the residents were not aware of information available on the American Academy of Ophthalmology Web site, and 92% did not consult the Academy Web site for information on new guidelines for coding.

Ninety-one percent of respondents considered themselves unprepared to adequately deal with billing responsibilities by the end of their residency. Conversely, 96% of respondents expressed the importance of incorporating additional training in coding and reimbursement during residency.

The majority of residents were able to correctly define an ICD-9 code and National Provider Identifier; however, the researchers reported that as the questions became more challenging, the number of correct responses decreased. Only 22% of residents could identify the criteria necessary to properly code for a consult and 22% could recognize the definition of a level 4 visit.

After analyzing the survey data, the researchers concluded that “adequate training in coding, reimbursement, and practice management appears to be lacking. This may be due to a combination of factors, such as a lack of emphasis by the ACGME (Accreditation Council for Graduate Medical Education) or lack of appropriate resources for residency programs to provide training. As a result, the majority of residents who responded to this survey feel unprepared in coding and reimbursement. Improved training in coding should therefore be incorporated in residency training programs.”

Carrying on “The Gift of Sight”

One humanitarian is inspired by another.

By René Luthe, Senior Associate Editor

■ After years of eye surgery missions to underdeveloped countries, Howard B. Goldman, MD, of Boca Raton, Fla., found his humanitarian efforts at something of a lull. His overseas trips with Florida Surgical Eye Expeditions — the Florida chapter of the international group he and Jerome Aronowitz, MD, formed in 1980 — had decreased in recent years, mainly due to the greater difficulties imposed on international travel for a crew of seven to eight staff and 50-plus boxes of supplies and instruments after the September 11th terrorist attacks. Then, there were what he called “close encounters of the wrong kind” that occurred on some of the trips to places like Mexico, Jamaica and Ecuador.

“One of our techs was stabbed when he walked in the wrong part of town in Guayaquil, Ecuador. He didn't really understand that he wasn't in the United States anymore and you don't just wander around in places that you don't know anything about,” Dr. Goldman explains. “I felt uncomfortable bringing people with family responsibilities who didn't understand how to behave in that kind of circumstance.” Additionally, the concerns of his family made Dr. Goldman more cautious about the missions. “Like my wife saying, ‘That's enough already!’”

Dr. Goldman saw another outlet for his desire to help others, however, when he read about the death of fellow ophthalmologist and Floridian Dr. Joel Shugar. Dr. Shugar had been well known in his community for his humanitarian efforts, which included his “Gift of Sight” initiative of performing free cataract surgeries for uninsured patients each year just before Thanksgiving. Dr. Shugar's family and staff had expressed the wish that “Gift of Sight” become a national effort, with cataract surgeons around the country honoring his memory through their participation.

“I thought, gee, that sounds like a really great idea,” Dr. Goldman says.

So in 2008 he contacted Caridad Clinic, where one of his retired partners offered his services. Dr. Goldman's practice had been performing free eye surgeries on Caridad patients on an occasional basis, but he hoped that in setting up their own “Gift of Sight Day,” they could treat additional underprivileged patients.

Howard Goldman, left, at his “Gift of Sight” day.

“It was a way of having a specific day when we would pick up as many of the clinic's surgical referrals as we could and take care of them,” Dr. Goldman explained. He persuaded Alcon to provide supplies, and his practice's anesthesiology group and all the physicians to provide their services free of charge.

“I was able to get everyone on board because it was close to a holiday when we consider how lucky we are in contrast to how difficult many of our neighbors have it.” Their Gift of Sight day is now scheduled for the Tuesday before Thanksgiving each year.

Dr. Goldman has also used his hobby, swimming, to give back. He participates in an annual long-distance race in a Maine lake where he vacations. He had toyed with the idea of participating in the Florida Keys Community College Swim Around Key West (12.5 miles) and seized it as another occasion to raise funds for Caridad.

“We did this challenge, where we put in our newsletter that I would personally match up to $1,000 any contributions to Caridad in recognition of the Swim. To my surprise, we raised over $5,000.” Dr. Goldman finished the race, swimming the 12.5 miles in a little less than nine hours. While it was “exhilarating” to do, Dr. Goldman reports that he won't be participating in the race this year. “I realized I didn't have the time to train the way one needs to for that kind of swim. I'm thinking about doing it again when I'm 65 (I'm 63 now). Two years ought to be enough time to build up to that again, but don't tell my wife. She thinks once was enough for that, too.”

Research Digest

New & Noteworthy Journal Articles

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Diet and cataract. The latest Carotenoids in Age-Related Eye Disease Study Group report, published in the June 2010 issue of Archives of Ophthalmology, reports that a healthy diet is strongly correlated with a lower incidence of nuclear cataract.

A total of 1,808 women formed the cohort on which this article was based. These women responded to questionnaires in order to determine compliance with 1990 Womens' Health Initiative (WHI) guidelines. Four to seven years later, the women underwent slit-lamp photography or phacoemulsification to determine nuclear cataract rates.

Of all variables examined, adherence to the WHI guidelines was the strongest modifiable predictor for low prevalence of nuclear cataract. Unsurprisingly, the CAREDS Study Group found high rates of correlation between cataract development, smoking and obesity, and they found a relationship between vitamin supplementation and lower cataract rates.

However, adherence to newer WHI guidelines, from 2005, were not correlated with lower incidence of nuclear cataract; the CAREDS Study Group believes higher intake of certain oils among adherents to the newer guidelines may be responsible for the lack of association.

► Post-phaco astigmatism. Despite advances in IOL power prediction, postoperative astigmatism remains a significant complication in phacoemulsification. A possible solution is the light-adjustable lens (LAL), an IOL that can be adjusted postoperatively using ultraviolet light. Having already conducted in vitro testing, a team of ophthalmologists from California and Mexico tested this hypothesis in five human subjects for an article appearing in the June 2010 issue of the British Journal of Ophthalmology.

The patients all had underwent phaco and had the LAL implanted, and all the patients experienced postoperative toric refractive errors of between 1.25 D and 1.75 D. Two weeks after IOL implementation, the IOLs were exposed to 365 nm of ultraviolet light to correct refractive error.

The study authors reported that all five of the patients treated experienced reduction of toric error, with all patients remaining stable for the nine-month follow-up period. Furthermore, all five members of the study cohort improved their uncorrected VA to ≥20/25 while maintaining BCVA. The authors argue that using an LAL is preferable to limbal relaxing incisions, LASIK, prescribing of glasses or using toric IOLs to adjust for postoperative refractive error.

► Prediction progression to glaucoma. Because ocular hypertension is considered to be one of the greatest risk factors for eventually developing glaucoma, ways of prediction progression to glaucoma are strongly desired. In the June/July 2010 Journal of Glaucoma, a team of UK scientists tested a three-way combination of the Heidelberg Retina Tomography, Moorfields Regression Analysis (MPA) and Glaucoma Probability Score (GPS).

The team tested in the combination in 198 patients with ocular hypertension, having the cohort undergo regular HRT and visual field testing between 1993 and 2001. Abnormal subtemporal MRA was found to be predictive of progression to glaucoma as measured on HRT in isolation; with the aid of odds ratios, abnormal global, superotemporal, superonasal and temporal MRAs were significantly associated with progression as measured by both HRT and visual field testing.

Furthermore, while GPS alone was not predictive of progression to glaucoma, a combination of GPS and abnormal MPA classification was. The study authors conclude that patients with this particular combination of measurements be monitored closely for changes in both HRT measurement and visual field testing.

► Costs of vision loss. According to a study in the June 2010 issue of Archives of Ophthalmology, a team of Japanese doctors report that the societal cost for visual impairment is substantial.

The study authors conducted a prevalence-based approach to the data, using vision worse than 20/40 as a threshold and taking cost information from several sources, including available Japanese health expenditure data and calculated disability-adjusted life years (DALYs), a quality of life measurement.

Of 1.64 million people in Japan with impaired vision, nearly 188,000 had experienced total or near-total vision loss. Direct financial costs for the treatment of visually impaired Japanese citizens was ¥1.3 trillion ($11.1 billion) in 2007. The largest percentage of this total cost was general medical expenditure, which accounted for nearly a trillion yen, or around $8.1 billion. Indirect financial costs were even greater, coming to almost ¥1.6 trillion ($13.1 billion). In terms of quality of life, the cost of vision impairment is 220,022 DALYs.

The authors estimate that 50% of the indirect costs of vision impairment in Japan are borne by community care facilities. They suggest that, barring a change in government policy, the burden will get even greater as, they hypothesize, vision loss is expected to increase by 23% in the next 20 years. They urge Japanese policymakers to plan for future costs. OM