Eyeworld

68 | EYEWORLD | APRIL 2022 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians Robert Maloney, MD Maloney-Shamie Vision Institute Los Angeles, California Tal Raviv, MD Eye Center of New York New York, New York A ccording to Tal Raviv, MD, coman- agement has been a part of oph- thalmology for more than 40 years as a means to coordinate surgical ophthalmic care among different provider types. "It has regained attention and scrutiny with the growth of refractive cataract surgery," he said. "But today's practice environ- ment is quite different from the past." Dr. Raviv noted some big picture trends in cataract surgery. As more baby boomers hit their cataract years and as the procedure is per- formed at a younger average age, the volume of cataract surgery is projected to steadily grow for the next few decades. "At the same time, cataract surgery is becoming concentrated to fewer high-volume surgeons due to decreasing third-party reimbursement and rapid refractive IOL innovation that requires significant capital investment in diagnostics and more specialized skills," he said. "These growing surgical prac- tices rely on a team approach for providing high-level surgical and postoperative care. This is a long-time practice in many other surgical specialties from cardiovascular to transplant surgery." For covered medical procedures, third-party reimbursement (such as Medicare) has coding provisions to allow each provider to bill for sur- gical or postoperative care, Dr. Raviv said, and for non-covered elective services, such as LASIK or the refractive surgery component of cataract surgery, cash payments are made by the patient. Robert Maloney, MD, said that the key issue is that the comanagement fee has to be propor- tionate to the amount of postop work required. There are two levels of comanagement in cat- aract surgery; the first is for standard cataract surgery, and the second is for cases with an advanced technology, such as the femtosecond laser or an advanced technology IOL. For standard cataract surgery, with Medi- care, Dr. Maloney said the postop care fee is 20% of the total surgical fee. If doctors are comanaging a Medicare cataract, the doctor bills Medicare for the surgical care only using the -54 modifier, and the comanaging doctor bills for the postop care using the -55 modifier. The comanagement fee covers the first 90 days of care after the surgery. Advanced technology IOLs require more work postoperatively. "AECOS [American-Eu- ropean Congress of Ophthalmic Surgery] is studying the postoperative work required by advanced technology lenses," Dr. Maloney said. "Our preliminary finding is that these lenses Comanagement in refractive cataract surgery If the needed postop correction is small, Dr. Koch said he'll propose PRK. Usually LASIK is not feasible, but sometimes he will do a flap recut and lift, if the cornea is amendable to further flap surgery. For residual refractive error of –2 or more or +1.5 or more, he prefers IOL exchange. As for taking lessons learned from the first eye and applying them to the second, Dr. Koch said it's more nuanced in post-refractive surgery patients. "If they've had a modest LASIK, you could probably learn something from the first eye, but if they've had a large LASIK correction, and especially in post-RK eyes, one cannot rely as much on the outcome of the first eye when calculating the IOL for the second one," he said. Dr. Williamson said that patients who are unhappy with their refractive outcome want to be heard and confident that their surgeon is understanding and has a plan for them. He said the staff often has an accurate pulse on just how unhappy a patient might be (e.g., the patient might be more honest with the staff than the physician). Dr. Williamson said it's important to remind the patient with a presbyopia-correct- ing IOL of what they do have—"awesome near vision"—and at 3 months postop consider more significant action if they're still not happy, such as a YAG capsulotomy (don't YAG too early, Dr. Williamson cautioned) or explant. "Never do [an explant] before a month unless it was a refractive miss," he said. "If you hit the refractive target … but the patient is un- happy with side effects, give it at least a month, then get it out and refund." continued from page 67

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