Superficial keratectomy. Corneal collagen crosslinking. Corneal culturing. Corneal foreign-body removal. Rebubbling (ugh!). Suture removal. The list goes on. These are all essential procedures in a cornea specialist’s clinic, but they can be a nightmare to perform without the proper set-up and support.

Setting up a clinic to perform in-office cornea procedures can be a complex and time-consuming process; however, with the right planning and execution, it can be a rewarding and profitable venture as well. Several key components must be considered, including staff buy-in, equipment, clinic flow and billing. In this article, we will explore how to tackle each of these components in detail as well as discuss how an ophthalmic society such as ASCRS can help you succeed.

STAFF BUY-IN

The most important component of setting up a clinic for cornea procedures is staff buy-in. It is essential to ensure that all members of the clinic staff are fully committed to the success of these procedures and are properly trained and equipped to perform them.

One of the first steps in ensuring staff buy-in is to educate all members of the clinic staff about the benefits of each procedure. In general, staff love it when doctors teach them! Most of us have been indoctrinated into the “see one, do one, teach one” mentality, but the truth is that technicians do not all learn this way. Instead, set aside half-day training with formal presentations about why a Descemet’s membrane endothelial keratoplasty (DMEK) may need to be rebubbled or what different types of bugs grow on different culture plates.

Motivated staff are the best asset of any clinic. Involve them in the process of setting up the clinic for procedures. This may include seeking their input and feedback on the protocol, equipment and supplies needed for the procedures.

When I joined my practice, none of my colleagues had experience doing DMEK. So, after I gave a presentation about the procedure, I showed staff some videos of rebubbling. I sat down with my technicians, a supply catalog and a white board, and we mapped out what would be needed and who would be responsible for ordering it.

By involving staff in the process, we created a sense of ownership and accountability among the team, which has led to greater success in the long term. Now, my team loves to joke with me about how they keep an eye on the supplies and without them I’d be in trouble (they are right)!

CLINIC FLOW

In addition to establishing a protocol, it is also essential to ensure that the patients are properly scheduled to prevent a clog in the schedule. Most practice management software and EMRs allow for different visit types, such as a post-op, dilated exam, cataract evaluation or procedure.

In my previous practice, Carol was the master of schedules. I have never seen someone so skilled at mapping out visits by the minute and determining what will allow for the best patient flow. For procedures, patients are booked for longer slots compared to non-procedure visits to prevent overbooking a patient. In fact, we reserve the last slot of the morning and afternoon sessions to account for potential excess time needed for procedures. This works well for procedures such as crosslinking, superficial keratectomies, phototherapeutic keratectomy and INTACS (Addition Technology).

When a patient is scheduled for a procedure, having the equipment already set up in the room is extremely helpful. For example, if a superficial keratectomy is on the schedule, having a #15 blade, speculum, bandage contact lens and burr next to the slit lamp can save time and add efficiency. Having protocols in place for diagnostics is also critical. For example, if a patient is post-op week one from a DMEK and is still experiencing blurry vision, having a protocol in place for the technician to get an anterior segment OCT and prepare the equipment for rebubble can save multiple trips in and out of the patient room for both the patient and surgeon.

Of course, not all procedures are planned. Should a corneal ulcer walk through the door, for example, suddenly you need culture plates and Kimura spatulas. This is where established protocols really help. My team knows that when I tell them I have to culture, they must grab all the relevant supplies, place them in the room with the patient, and then let me know they are ready. I can walk in, culture everything in 2-3 minutes and hand off the plates.

BILLING

Billing is one of the most critical components of setting up a clinic for cornea in-office procedures. While this is not typically what motivates any of us to do what we do, it is essential to understand the reimbursement process for these procedures and to ensure that your clinic is properly billing for them. Success in setting up your clinic requires you to consider several factors when it comes to billing. These include the type of procedure performed, the type of insurance the patient has, and the fee schedule established by the insurance company.

One of the first steps in the billing process is to establish a fee schedule for each type of procedure performed in the clinic. This fee schedule should consider the cost of the procedure, the time and resources required to perform it, and the expected reimbursement from insurance companies. The fee schedule should also be reviewed and updated regularly to ensure that it remains accurate.

In addition to establishing a fee schedule, it is also essential to understand the reimbursement process for each type of insurance that your clinic accepts. This includes understanding the reimbursement codes for each procedure and the requirements for submitting claims to each insurance company. To make this process easier, I strongly recommended you work with a billing specialist who has experience with in-office cornea procedures.

This is also where ASCRS can help. When I started the process, I reached out to members of the ASCRS Young Eye Surgeons (YES) committee and asked if anyone had the CPT codes for common in-office procedures. Within hours, the online community gave me the codes for procedures in 2023 including corneal biopsy, corneal culturing and superficial keratectomy. Please note, that these codes are subject to change.

1. Corneal biopsy: 65400
2. Corneal culturing: 65430
3. Intrastromal injection: 66030
4. Subconjunctival injection: 68200
5. Superficial keratectomy: 65400
6. Corneal collagen crosslinking: 0402T
7. INTACS: 65785

HELP FROM OPHTHALMIC SOCIETIES

ASCRS can be a valuable resource for those looking to set up a clinic for cornea in-clinic procedures. The society provides its members with a range of resources and support for clinics and practitioners, including educational resources, networking opportunities and advocacy efforts.

The ASCRS Annual Meeting offers a range of educational programs and workshops designed to help clinics and practitioners stay up to date with the latest developments in the field of cornea in-clinic procedures. These programs cover a range of topics, including the latest surgical techniques, patient-selection criteria, and billing and coding. In fact, a symposium at ASCRS 2022 led by Dr. Marjan Farid on in-ooffice corneal procedures went through the specifics of how to get started.

When preparing to enter my practice, I sat through some very helpful coding workshops at the 2021 Annual Meeting in Las Vegas. By taking advantage of these programs, clinics and practitioners can gain the knowledge and skills needed to provide high-quality care to their patients while growing their practice’s bottom line.

In addition to educational programs, ASCRS also offers a range of networking opportunities. These allow practitioners to connect with other professionals in the field, exchange ideas and best practices, and collaborate on research. This network can be a valuable resource for clinics and practitioners looking to establish themselves in the field. Between the annual meeting, webinars and online programming, and the YES committee, ASCRS makes itself as available as the member wishes.

CONCLUSION

In-office clinic procedures are an important aspect of a cornea specialist’s practice. By considering factors such as billing, clinic flow and staff buy-in, clinics can ensure that they are well-positioned for success. Thankfully, the resources and support offered by ophthalmic societies such as ASCRS enable clinics and practitioners to both stay up to date with the latest developments in cornea and connect with experienced professionals in the field. OM

Brian M. Shafer, MD, is a cataract, refractive, cornea and glaucoma surgeon, founder at the Shafer Vision Institute and an adjunct assistant professor of ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Dr. Shafer has no relevant financial disclosures.