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Cataract & Implant

Co-Management

POLICY AND PROCEDURE MANUAL

California optometric laser associates

California Optometric Laser Associates

Co-Management of Cataract and Implant Patients

Policy and Procedure Manual

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Step-by-Step Process for Cataract Surgery Co-Management

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Treatment Protocols: What to Look for Pre and Post-Operatively

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Cataract Co-Management Billing for Medicare Patients

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Sample Medicare Billing

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Supplemental: Clinical Forms

Cataract Co-Management Treatment Plan (Patient Handout) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Cataract/Implant Co-Management Pre-Op Exam and Consult Request Form . . . . . . . . . . . . . 13

Co-Management Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Surgeon Consult Results Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Co-Management Transfer of Care Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Sample Post-Operative Exam and Medication Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Cataract/Implant Post-Operative Exam Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Payment Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 1

Introduction

Patients choosing co-management for their pre- and post-operative surgical care experience the

beneﬁts of continuity of care by their Primary Eye Care Provider (PECP) and convenience. is manual

outlines the process for the co-management treatment of cataract and implant surgery patients.

Together with some of California’s most experienced cataract and implant surgeons, co-managing

doctors of optometry can provide high quality care for cataract and implant patients, consistent with

patient needs and desires.

e following guidelines comply with applicable state and federal statutes and regulations regarding

co-management of patient care and referral arrangements.

1. e selection of an operating surgeon for patient referral will be based on providing the

best potential outcome for the patient. Financial relationships between providers will

not be a factor.

2. e patient’s right to choose the method of post-operative care will be recognized and

will be consistent with the best medical interest of the patient.

Co-management of post-operative care will be determined on a case-by-case basis and

not prearranged. e patient will be advised prior to surgery of potential post-operative

management options.

Co-managing doctors will be ODs or MDs licensed to practice in California.

5. e transfer of post-operative care will always be clinically appropriate and depend on

the particular facts and circumstances of the surgical event.

6. Following surgery, transfer of care from the operating surgeon to a co-managing

provider will occur when clinically appropriate at a mutually agreed upon time or

circumstance, and such time will be clearly documented via correspondence and

included in the patient’s medical record. is information will be included in the referral

letter from the ophthalmic surgeon to the co-managing provider at the time of transfer

of care.

7. e operating surgeon and the co-managing provider will communicate during the post-

operative period to assure the best possible outcome for the patient.

8. Compensation for care will be commensurate with the services provided. Cases

involving care for Medicare beneﬁciaries will reﬂect the proper use of modiﬁers and

other Medicare billing instructions.

Step-by-step instructions and co-management forms are provided in the following section of this

manual.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 2

Step-by-Step Process for Cataract Co-Management

1. q e referring optometrist performs the following:

a. q

Perform exam and identiﬁes need for cataract surgery.

b. q

Educate the patient regarding the process of cataract surgery and discuss fees.

c. q

Discuss the typical co-management treatment plan and explain what care will be provided by the

ophthalmic surgeon and the optometrist. Provide the patient with Patient Handout (page 11).

d. qF

ax the Pre-Op Examination and Consultation Request Form (page 13) to the COLA MD’s

oﬃce.

e. qH

ave the patient sign the Payment Authorization Form (page 19) and the Co-management

Consent Form (page 14) and fax the forms to both the MD’s oﬃce and the COLA administrative

oﬃces.

2. q

e Patient Coordinator (PC) at the MD’s oﬃce performs the following:

a. qC

ontact the patient and schedule an appointment for a consultation.

b. qN

otify the referring optometrist of the date of the consultation appointment, or the reason the

patient declined to book the appointment, if applicable.

3. q

e surgeon performs the following:

a. qPr

e-op exam and pre-op testing

b. qP

atient education and procedure selection

c. qF

axes Surgeon Consults Results Form (page 15) to the co-managing eye care provider, advising

the date of surgery, patient ﬁndings and plans, and any other pre-op care instructions.

d. qC

omplete the Transfer of Care Form (page 16) (when deemed medically appropriate), which

includes surgery information and ﬁndings from the previous post-operative visits and faxes the

form to the co-managing PECP.

4. q

e co-managing PECP performs the following:

a. qF

ollowing each post-operative visit, fax Cataract/Implant Post-Operative Form (page 18).

Usually at the one month visit, the PECP will perform the post-operative follow-up, refraction and

prescribing glasses, if necessary.

b. qB

ill third party payers for their portion of the post-operative treatment. Information regarding

billing the PECP’s portion of the co-managed care is provided on pages 14-16 of this manual.

5. qP

ayment for upgraded IOLs or private pay services will be collected from the patient by the

California Optometric Laser Associates and reimbursement will be made by COLA, inc. to the

PECP for those services.

e MD’s oﬃce will communicate with the referring provider via fax for any matter regarding their patients,

including procedure outcomes and any follow-up visits seen by the surgeon.

Please contact the MD directly for any questions regarding individual patient care or complications.

For ordering necessary supplies, questions regarding payment or general questions about

COLA co-

management programs, please contact a COLA representatives at 510-895-9657.

We look forward to bringing together a partnership with our aﬃliated co-managing doctors in which cataract

and implant patients can receive the best and most convenient available care.

Disclaimer: Every eﬀort has been made to assure that all information contained in this manual is accurate, appropriate and

current with the standards of care in the State of California. COLA takes no responsibility for the payment of individual

insurance claims by Medicare or any other third party insurance. All medical care and advice is at the discretion of each

MD’s and OD’s clinical judgment.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 3

Treatment Protocols

e volume of cataract surgeries will continue to increase as the population ages. So, we must stay

educated in cataract surgery protocols and possible complications. A thorough pre-op exam and

treatment of any existing problems may prevent complications from occurring after surgery. ough

serious complications are rare, it is also important to know what post-op complications can occur and

how you can manage them, and when it is time to refer the patient back to the surgeon.

PRE-OP EXAM

General Health

e ﬁrst key to managing complications is to ﬁnd ways to avoid them altogether or at least decrease

their likelihood. is starts with astute observations during your pre-operative exam, and that starts

with a general health history. Understanding the patient’s overall health at the time of surgery can

help chart the strategy of the procedure. It can also help predict and explain the prognosis and course

of recovery.

Ask about systemic diseases that aﬀect healing after cataract surgery, particularly autoimmune and

collagen vascular diseases such as rheumatoid arthritis, lupus and diabetes. Patients with

rheumatoid arthritis are at risk for abnormal healing. Examine the patient’s hands for telltale signs.

Arthritis or lupus may increase the inﬂammatory response after surgery, resulting in pronounced post-

op inﬂammation, high intraocular pressure, cystoid macular edema or even a corneal melt near the

incision.

If the history is positive for any of these diseases, you may have some options to help provide that

patient with a normal post-op healing course. e surgeon could consider more inert intraocular lenses

(IOLS) made of acrylic instead of silicone, which would reduce a potential source of inﬂammation. Be

prepared for the need to increase the steroid dosing early in the post-op period to control the ensuing

inﬂammatory response.

ere are some concerns speciﬁc to diabetic patients: poor wound healing, and the risk exacerbating

existing proliferative retinopathy and diabetic macular edema. Diabetics with poor blood sugar

control may have a slower recovery following surgery. Some may beneﬁt from delaying surgery until

their diabetes is under control.

Anterior Segment Concerns

Examination of the eyelids prior to surgery should not be overlooked. e leading cause of

endophthalmitis is the introduction of bacteria into the eye from the conjunctiva and ocular adnexa.

It’s important to diagnose and manage blepharitis and meibomitis prior to cataract surgery.

Also, look for other lid conditions such as entropion, ectropion and lower lid laxity. Improper

apposition of the lower eyelid can contribute to an inadequate clearing of bacteria, which also increases

the risk of endophthalmitis. You may want to refer these patients for an oculoplastic consult prior to

cataract surgery.

Patients with cranial nerve dysfunction such as a seventh-nerve palsy, which results in an

complete blink, are also at risk for corneal exposure problems and poor wound healing after cataract

surgery. Lubricating ointments and a referral for surgical intervention may be indicated for these

patients.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 4

Pterygia, epithelial basement membrane dystrophy, Salzmann’s nodular dystrophy or band

keratopathy can prevent accurate measurements and limit vision. To accurately assess the cornea

for proper IOL power calculations, crisp and regular mires on the keratometer or topographer are

essential. Discuss this with the patient prior to surgery to help manage post-op visual expectations.

ese patients may beneﬁt from corrective surgery prior to the cataract procedure, which would

provide for better corneal measurements and improved corneal transparency.

Two additional corneal conditions to consider in counseling patients:

Fuchs’ dystrophy • Patients with moderate to advanced Fuchs’ are at risk of

permanent corneal edema due to the strain that cataract surgery can put on already

debilitated endothelial cells. Patients with signiﬁcant Fuchs’ dystrophy may beneﬁt

from a triple procedure, that is simultaneous cataract extraction, IOL implantation and

corneal transplantation.

2. Herpes simplex keratitis • e Herpetic Eye Disease Study (HEDS) and other studies

have shown that previous episodes of herpes simplex stromal keratitis are the single

greatest contributing factor to subsequent bouts of recurrence. Trauma may also trigger

recurrence. Because surgery involves some trauma to the eye, the surgeon may consider

treating these patients prophylactically with oral antivirals before and after surgery.

Cataract surgery may be contraindicated if an episode of HSV keratitis has occurred

within the last 6-12 months.

Additional Pre-Op Concerns

Counsel patients with conditions that can result in weak zonular ﬁbers, and in turn, increase the

risk of a capsular rupture or tear. ese include Marfan’s syndrome, Ehlers-Danlos syndrome,

previous trauma and pseudoexfoliation. Patients with a traumatic cataract secondary to an impact

injury are at heightened risk of capsular rupture potential.

Pseudoexfoliation is the most common of these conditions. e surgeon will usually be prepared for

otentially suturing the IOL in place or consider using a capsular tension ring, which might aid in

centration of the IOL within the capsular bag.

Also perform a thorough dilated fundus examination to identify any pathology that may limit

best visual acuity post-operatively or contribute to retinal tears or detachments following surgery.

Consider referring patients with peripheral areas of weakness for prophylactic treatment prior to

cataract surgery. Warn patients with a history of toxoplasmosis or histoplasmosis of the risk that the

conditions could reactivate following cataract extraction.

Post-Op Visits

During these visits (see schedule, page 17), you need to assess the early stages of recovery and rule out

any serious problems. Most complications after cataract surgery present early in the post-op period

and will be resolved by the time the patient is released by the surgeon.

Review the post-op medication regimen that is prescribed, conﬁrm compliance and clarify any

questions the patient may have about his or her recovery. A post-op kit and instructions will have been

provided to the patient.

Treatment Protocols, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 5

Key Exam Areas

During your post-op exams, pay careful attention to these key areas:

Visual

Acuity • It is not unusual for the patient to have reasonably good acuity immediately post-op.

More mature cataracts, however can often result in a delayed return of acuity. is is due to corneal

edema from the higher levels of phaco energy used during the procedure. (Corneal edema, in fact, is

the most common cause of decreased vision on day one post-op.)

Given the variety of correction strategies available, including monovision corrections and multifocal

IOLS, you should know what corrective strategy or targeted refraction the surgeon chose before you

examine the patient.

e Incision • Carefully inspect the incision for any evidence of poor healing or a wound leak. Signs

ssociated with this problem are a shallow anterior chamber, an IOP of less than 10mm Hg, and some

degree of corneal edema. A Seidel’s test with ﬂuorescein can help you verify a wound leak.

Wound leaks are a serious issue. Not only do they delay visual recovery, but they put the patient

at risk of intraocular infection or choroidal hemorrhaging due to the low IOP. Wound leaks require

consultation with the surgeon. Signiﬁcant wound leaks may require suturing for repair, while smaller

leaks can usually be controlled by temporarily reducing the steroid medication and applying a bandage

contact lens for a few days.

Corneal Integrity • Assessment of the cornea’s overall status can help you anticipate when the

patient will recover best visual acuity.

Stromal herpetic disciform keratitis can recur after cataract surgery. Cataract surgery may be

contraindicated if an episode of HSV keratitis has occurred within the last 6-12 months.

Depending on the diﬃculty and length of the surgery, the cornea can respond with varying degrees

of edema and endothelial folds. In an uncompromised cornea, swelling will limit vision early on,

but this tends to dissipate within the ﬁrst week post-op, resulting in improved acuity. Patients with

compromised corneal endothelial cell function or Fuch’s dystrophy can expect corneal edema to

diminish more slowly, but they still tend to do well long-term.

Whenever you note signiﬁcant corneal edema, be sure to consider IOP. A cloudy cornea with signs of

microcystic edema is often a sign of elevated IOP following cataract surgery.

ough rare, corneal abrasions can develop immediately following cataract surgery. We can usually

resolve this problem with a bandage contact lens for one or two days. Also we can temporarily decrease

steroid usage to allow for improved epithelial migration; this can help the abrasion resolve more

quickly.

Anterior Chamber Status • At day one the anterior chamber should appear well formed with

moderate cellular reaction. A ﬂat or shallow chamber may indicate a wound leak.

e cellular reaction can be more pronounced in diﬃcult cases, but ﬁbrin within the anterior

chamber or the presence of hypopyon is never normal. A dense anterior chamber reaction with visual

obscuration of the anterior segment anatomy indicates bacterial endophthalmitis, which requires

immediate attention and culturing.

Treatment Protocols, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 6

IOL Status Within the Capsular Bag • IOL decentration/dislocation is not common with

uncomplicated surgery. Most IOL dilocations result from trauma, known zonular weakness or in

association with a tear in the posterior capsule. Dislocations usually occur months to years after the

original procedure.

Review any evidence of IOL dislocation with the surgeon. e surgeon may need to explant the IOL

and then place it within the ciliary sulcus, or suture the implant in place.

Besides examining the implant location, carefully inspect the integrity of the capsular bag. Early

wrinkles within the posterior capsule can cause minor visual distortion or streaking of lights.

Fortunately, these tend to fade throughout the early post-operative period as the capsule shrinks.

In cases of posterior subcapsular cataracts, it is not uncommon to have early post-operative

opaciﬁcation of the posterior capsule in the ﬁrst few weeks post-op. is is due to a higher degree

of remaining lens epithelial cells that adhere to the posterior capsule after surgery. Patients with

posterior capsule opaciﬁcation can undergo Nd:YAG laser capsulotomy months after the initial cataract

surgery. is is most likely needed one year post-op.

Keep in mind, however, that YAG procedures carry a short-term risk of an immediate IOP spike. You

an usually control this with topical IOP-lowering agents in conjunction with a short course of topical

steroids. Historically, alpha agonists have proven to work well with anterior laser surgery.

YAG laser capsulotomy also carries a long-term risk of retinal tear or detachment. So, it is important

o perform a dilated fundus exam on these patients within a month after surgery. Several research

studies are investigating diﬀerent IOL designs and materials that will hopefully reduce the incidence of

posterior capsule opaciﬁcation.

Posterior capsule rupture has been cited in up to 4.1% of all cataract surgeries. Tears of the posterior

apsule that occur during surgery require special care to prevent loss of lens fragments within the eye.

Evidence of free lens fragments post-operatively should be evaluated by the surgeon. ese loose

particles can lead to chronic inﬂammation and IOP elevation, and thus need to be dealt with carefully.

Intraocular Pressure • IOP spikes in the immediate post-op period occur in 5-14% of all cataract

surgeries. Several studies have linked the viscoelastic substance used to ﬁll the anterior chamber

with the incidence of a 24-hour post-op pressure spike. Failure to completely aspirate and remove the

protective viscoelastic substance at the end of the cataract procedure temporarily inhibits the normal

aqueous outﬂow from the anterior chamber.

Patients who present with pressures higher than 30mm Hg may complain of a dull headache or pain in

d around the eye. A steamy cornea that indicates diﬀuse microcystic edema typically manifests with

pressures at or above this level. You may need to refer this patient back to the surgeon for an anterior

chamber tap through the paracentesis to immediately reduce IOP.

If the anterior chamber tap is not an option, you can prescribe a topical pressure-lowering agent such

s a beta-blocker, an alpha adrenergic agonist, or a carbonic anhydrase inhibitor – either alone or in

combination – to reduce the pressure. (Of course, beta blockers are contraindicated in patients with a

history of respiratory problems and may be contraindicated for those on similar therapy for high blood

Treatment Protocols, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 7

pressure.) Once IOP is within normal limits, recheck the patient in 24-48 hours to rule out a rebound

spike. Typically, IOP will have stabilized at the one-week visit, and it will be safe to discontinue the

pressure-lowering drops.

Serious Complications

Some of the more serious though less frequent complications associated with cataract surgery include:

Endophthalmitis • is bacterial intraocular infection occurs in about 0.05-0.7% of cataract

surgeries. e usual source of infection is the patient’s own ocular surface, and most cultures are gram-

positive organisms at work.

Although rare, endophthalmitis is the biggest emergency we face. Early diagnosis and treatment are

critical. Without prompt treatment, the patient could lose an eye.

A patient with endophthalmitis presents with a red, photophobic eye, usually within a few days after

urgery. One important symptom is the presence of unusual pain and blurred vision early in the post-

op period. Upon slit-lamp examination there will be a marked anterior chamber reaction with possible

ﬁbrin and hypopyon.

Refer patients back to the surgeon immediately for intraocular culturing, intraocular antibiotics and

possible vitrectomy.

Cystoid Macular Edema • CME often presents with unexplained decreased acuity within the ﬁrst

few weeks after surgery. At times, it can present nearly a month after surgery and persist for several

months before it spontaneously resolves.

CME may be diﬃcult to detect on fundus examination alone. Indeed, ﬂuorescein angiography may be

e only way to deﬁnitively diagnose the condition. Optical coherence tomography has shown that

CME can develop in uncomplicated surgery.

Retinal Detachment • e likelihood of retinal detachment after uncomplicated cataract surgery

is less than 1%. Complicated cases involving posterior capsule rupture and vitreous loss increase

the likelihood of retinal problems after surgery. e incidence does rise in highly myopic eyes,

necessitating detailed retinal examination and prophylactic treatment of lesions that could contribute

to a retinal detachment.

e California Optometric Laser Associates and aﬃliated surgeons are committed to

providing

Continuing Education for the pre and post-operative management of surgical

patients. We have provided an overview of treatment protocols in this manual, however, we

encourage you to attend our Continuing Education seminars for discussions regarding these

protocols. Please contact our surgeons any time if there is a question regarding pre and

post-operative patient care.

Treatment Protocols, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 8

Cataract Co-Management Billing For Medicare Patients

As per guidelines published by Medicare in 1992, speciﬁc components of major surgery were

deﬁned as the “global surgery package.” e components they identiﬁed included pre-operative

care, intraoperative services, post-operative care (90 days), and in-oﬃce care for any post-operative

complications. In addition, the value of post-operative care for surgical procedures was standardized

and post-operative care for ophthalmic surgery was valued at 20% of the global surgery package.

Medicare also published instructions to Medicare carriers on split billing of post-operative care,

also known as post-operative co-management, within eye care. ese instructions incorporated the

following points, which are further deﬁned in this section of our co-management manual:

1. Co-management requires a written transfer agreement between the surgeon and the

receiving doctor(s).

2. Speciﬁc modiﬁers must be used on claims (54 – surgical care only; 55 – post-operative

management only.)

3. e receiving doctor cannot bill for any part of the service included in the global period

until he/she has provided at least one service.

Written Transfer Agreement

e transfer agreement between the surgeon and the co-managing doctor (optometrist) contains the

surgeon’s discharge instructions and the eﬀective transfer date. According to current Medicare policy,

the transfer date is “determined by the date of the physician’s transfer order.”

e responsibility for post-operative care may be transferred on or before the patient’s appointment

for the subsequent follow-up visit with the receiving doctor, who may submit a claim for services once

he has seen the patient.

e split of post-operative care cannot be done or pre-arranged in advance of the surgery. Instead,

a unique transfer agreement should be constructed for each patient. e essential elements of the

Transfer Care Form from the surgeon to the optometrist should include the following (see Page 16)

Patient Name

Operative Eye

Nature of Operation

Date of Surgery

Clinical Findings

Discharge Instructions

Transfer Date

e optometrist should assume care of the patient on the following day. is form determines the

“transfer date,” as well as corresponding reimbursement for claims submitted. Because the surgeon

cannot be certain the patient will actually keep the appointment with the optometrist, communication

from the optometrist is necessary and is evidence that the optometrist actually saw the patient, and is

in compliance with CMS’s requirement that the optometrist “has provided at least one service.”

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 9

Essential elements of the transfer agreement from the optometrist should include the following:

Patient Name

Operative Eye

Nature of Operation

Transfer Date

Results of First Post-Operative Visit

Both Doctors should retain copies of this documentation as part of the patient’s permanent records.

ey may also serve as a useful attachment on claims, as necessary.

Modiers for Claims Submission

Immediately following surgery, the surgeon can submit a claim for the surgical component of care

using the appropriate CPT Code, i.e. 66984, and Modiﬁer 54. is modiﬁer is used to indicate the

surgical event in a co-managed case. Medicare assigns 80% of the global fee to the intraoperative

service.

Later the surgeon will submit a claim for his/her portion of the post-operative care. In order for this

laim to be accurate, the surgeon needs to know the date the optometrist assumed responsibility for

the remaining post-operative care (the transfer date noted above). is claim will be ﬁled using the

appropriate CPT Code, i.e. 66984, and Modiﬁer 55, which indicates post-operative management only.

After the optometrist has seen the patient for post-operative care, he/she will submit a claim for the

ost-operative care provided, using the appropriate CPT Code, i.e. 66984, and Modifer 55. Again, in

order for the claim to be accurate the optometrist must know the date he/she assumed responsibility

for post-operative care (the transfer date).

Medicare uses chronology and number of days to calculate payment for care rendered by each doctor

dur

ing the post-operative period (90 days). e fees submitted by the surgeon and optometrist will be

diﬀerent, depending on the number of days of post-operative care each one provided. An example of

billing by the surgeon and optometrist follows.

Cataract Co-Management Billing For Medicare Patients, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 10

Sample Medicare Billing

Surgeon’s Care PECP (OD’s) Care

Date

January 1:

January 2-10

CPT Code

66984-54

66984-55

Date

January 11-April 1:

CPT Code

66984-55

Reimbursement of care is valued at 20% of the

lobal surgery fees. In this example, value of the

post-op care is apportioned to the surgeon as

follows:

10/90th of 20% to the surgeon

(10 days)

Reimbursement of care is valued at 20% of the

global surgery fees. In this example, value of the

post-op care is apportioned to the PECP (OD) as

follows:

80/90th of 20% to the optometrist

(80 days)

When submitting claims, many Medicare carriers instruct providers to write a comment in the body of

e claim form, as follows:

Surgeon: “Assumed post-operative care on January 2, relinquished care on January 20.”

Optometrist: “Assumed post-operative care on January 11, relinquished care on April 1.”

Overlapping Post-Operative Co-Management

Many patients will have cataract surgery performed on the second eye shortly after their ﬁrst surgery,

in which case post-operative care may overlap temporarily. When these patients are co-managed,

claims for each surgery are handled separately. e surgeon will ﬁle the second claim with Modiﬁer 79,

to indicate the second surgery is unrelated to the ﬁrst (diﬀerent eye). Both surgery claims will also be

ﬁled using Modiﬁer 54, to indicate post-operative care is being co-managed. e post-op care claims

will include both Modiﬁers 55 and 79 for the surgeon and the optometrist.

e chronology and windows of time on which payment is determined (as outlined above) are still

relevant and the claims will be concurrent. e surgeon will determine if the transfer of care for the

ﬁrst surgery occurs before or after the second surgery.

If the transfer of care for the ﬁrst surgery occurs before the second surgery, then two transfer of care

letters or forms and transfer agreement letters must be prepared, established a unique transfer date

for each surgery.

e comments provided herein relate to billing for cataract co-management for Medicare patients.

Commercial carrier policies will vary. Should you have questions about a speciﬁc carrier’s policy,

we recommend you contact them directly. Also, if you have questions related to Medicare billing

procedures, you can visit their website, www.cms.gov, or contact our oﬃce for assistance.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 11

Patient Information Sheet

Patient Handout

Cataract Patient Co-Management Treatment Plan

is information is designed for patients who have been diagnosed as having cataracts and who intend

to have cataract surgery. Any surgical procedure contains some element of risk in the post-operative

period. For your health and safety, it is imperative that you receive proper follow-up care after your

cataract surgery. is fact sheet will explain what follow-up care is, and who is qualiﬁed to perform it

for you.

What is Follow-Up Care?

After your cataract surgery, you will have several appointments with an eye care professional. You

should understand that complications may not necessarily occur during surgery, but may occur after

the surgery had been performed. For this reason, it is imperative that you have appropriate care by

a qualiﬁed eye care professional following our surgery. He or she will perform tests to measure your

visual acuity and, ultimately, if necessary, ﬁt you for eyeglasses. In addition, your doctor will ensure

that any post-surgery complications are detected and treated. is series of visits is called your “follow-

up care.”

Who is Qualied to Provide Follow-up Care?

It is critical that your follow-up care be performed by a qualiﬁed eye care professional familiar with

your case. Several diﬀerent practitioners are qualiﬁed to provide this service. You should understand

the roles that each may play in your recovery.

Your Surgeon • Your surgeon is a licensed ophthalmologist, a medical doctor who specializes in

diseases of the eye and who will implant your lens. Your surgeon will always see you one day after

surgery to ensure that your recovery is progressing normally. Your surgeon will also determine when

you can be released from his or her care to return to your optometrist for further follow-up visit as well

as post-operative glasses, if needed.

Your Optometrist • While you may request to receive your follow-up care from your surgeon,

Doctors of Optometry are eye care professionals trained, licensed, and fully qualiﬁed to provide follow-

up care once you are “released” by your surgeon. Most patients ﬁnd it very convenient to return to

their optometrist for post-operative care and services. Your optometrist is also the vision specialist

who will examine and ﬁt you for your glasses, if necessary, after recovery. Your optometrist will be in

communication with your surgeon following each post-operative visit. If problems develop during the

post-surgery follow-up period, your optometrist and your surgeon will communicate regarding your

care until these have resolved.

Another Ophthalmologist • If you travel away from home to have surgery and wish to return home

soon after surgery, or if you have any other personal reason for not receiving your follow-up care

from your surgeon or optometrist, you may decide to see another ophthalmologist for your follow-up

care. An ophthalmologist other than your surgeon can perform all of your follow-up care after your

initial visit with your surgeon one day after surgery. You must, however, make arrangements with the

ophthalmologist and notify your surgeon before having surgery. Your surgeon will only discharge you

from his or her care if he or she has conﬁdence in the professional who will supervise your recover.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 12

Summary

We hope this summary has helped to explain some facts about the cataract surgical process. Your

optometrist and surgeon will explain the improvements in your vision that you may enjoy after

cataract surgery. If you have any questions or concerns, now is the time to raise them. You may contact

your optometrist or your surgeon at any time, before or after surgery, to answer your questions.

Notes

____________________________________________________________________________________

Patient Treatment Plan, Cont.

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 13

Cataract/Implant Co-Management Pre-Op Exam & Consult Request

Use this form when referring your patient for surgery who desires to return to you for follow-up care during the 90 day global period.

Co-Managing PECP ________________________ Phone ________________ Fax ________________ UPIN#________

Address ____________________________________________________________________________________________

Oﬃce Contact ________________________________ Email Adress __________________________________________

Surgeon ____________________________________________________________________________

Patient Info

Name __________________________________________________ D.O.B. ____________ Date ____________

Home Phone _______________________ Work _______________________ Cell ________________________

Clinical Info

Reason for Consultation: ______________________________________________________________________

Ocular History _____________________________________ Medical History__________________________

Examination VAsc OD ____________ VAcc OD ____________ Pupils (dim light) _________________

OS ____________ OS ____________ Fields _______ EOM _______

Near Vision OD ____________ OS ____________

Keratometry OD _________________________ OS _________________________

Manifest Refraction OD ________________________________________ 20/

OS ________________________________________ 20/

IOP (Goldman/Non Con/Other) OD _________________________ OS _________________________

Slit Lamp Exam Dry Eye Testing - Method ______________________________

OD __________________________ OD __________________________

OS __________________________ OS __________________________

Dilated Fundus Exam Topography OCT

OD _________________________ OD _________________________ OD _________________________

OS _________________________ OS _________________________ OS _________________________

Type of CLs _________________________________ Time out of CLs _________________________________

q Best corrected VA is 20/40 or less, even with glare testing

q Limitations of presbyopia discussed

q Activities of daily living are impaired because of decreased vision q Presbyopia-correcting lenses discussed

Additional Comments _________________________________________________________________________

Fee Quoted _________________________________________________________

Fax completed form to MDs Oﬃce ______________________________

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 14

Co-Management Consent

To be completed by Co-Managing PECP or Surgeon – Please keep in Patient File

Pati

ent Name: _____________________________________________

Dr. ___________________________ will be performing ______________________________ on me.

It is my desire to have my primary optometrist/ophthalmologist, Dr. ___________________________

perform my pre-operative and/or post-operative care.

I understand that a record of ﬁndings will be sent to my surgeon following each visit with my primary

ye care provider and that my surgeon will be informed if I experience any complications related to my

eye surgery. I understand that I may also contact my surgeon at any time after the surgery.

I understand that there are no additional fees associated with co-management and that the California

Optometric Laser Associates will collect outstanding fees, if any, above those individually billed to

insurance and forward the appropriate co-management fee to Dr.

___________________________ for

ost-operative care.

Date _____________

Signature _________________________________

Witness _________________________________

Please fax to MD and to COLA Administrative Oﬃce: 510.895.9680

NAME OF SURGERY

NAME OF PECP

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 15

Surgeon Consult Results Form

To be completed by Surgeon and faxed to Co-Manager

Surgeon Name ____________________________________________

Date __________________

Co-Managing PECP ______________________________________ Fax ____________________

Patient Name __________________________________ D.O.B. __________ q OD q OS q OU

Dear Doctor,

ank you for referring this patient for cataract/implant evaluation. At this time:

qAttempts to contact this patient have been unsuccessful. Please contact our oﬃce so

that we can verify patient contact information.

qis patient has scheduled an appointment for consultation. e date of the

consultation is _________________

qis patient has opted NOT to schedule a consultation for surgery at this time. e

patient’s stated reason is:

_______________________________________________________________________

We have seen this patient for consultation. At this time:

qis patient has been scheduled for surgery. e date of surgery is _________________.

Please expect to receive a Transfer of Care form following surgery if co-management is

indicated for this patient. A surgery report will be sent.

qis patient has NOT been scheduled for surgery. e reason that surgery has not been

scheduled is:

_______________________________________________________________________

Patient Billing More than one item may be checked

qis patient is a Medicare patient. Please bill Medicare directly for post-operative fees

related to that portion of the surgery. If you are not a Medicare Provider, please contact

our Co-Management Coordinator.

qis patient is NOT a Medicare patient or has supplementary insurance. A

representative will contact you regarding billing arrangements indicated by this

patient’s plan.

qis patient is not covered by insurance. All services will be the responsibility of the

patient.

qis patient has opted for additional non-covered procedures or lens upgrades.

Questions? Please contact the Co-Managment Coordinator at

___________________________________________________

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 16

Co-Management Transfer of Care Form

Surgeon Name ____________________________ Phone ________________ Fax ________________

Patient Name _____________________________ D.O.B. __________ Home Ph _________________

Medicare # __________________________ Other Insurance _________________________________

Date of Surgery ______________________________q OD q OS

Procedure/Lens ______________________________________________________________________

Diagnosis Code ____________________________________ CPT Code _________________________

Facility _____________________________________________________________________________

Co-Managing Optometrist or Opththalmologist ____________________________________________

Date Post-Op Care Began ____________________ Date Post-Op Care Ended _____________________

Post-Op Uncorrected VA: OD 20/_________ OS 20/_________

Post-Op Exam Findings ________________________________________________________________

____________________________________________________________________________________

Medications:

Post-Op visits to schedule for this patient:

q______________________ q 30 Day q 90 Day q 6 Mo q 1 Yr

Surgeon Signature _______________________________________ Date ______________________

MD: Fax to co-managing OD

I accept the Transfer of Care for the above-mentioned patient

PECP Signature _________________________________________ Date ______________________

Fax signed form back to MD

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 17

Sample Post-Operative Examination & Medication Schedule

Outlined below is a brief description of a typical cataract post-operative schedule. It is important

that patient follow-up care be documented in written form, not only for medical, but for medical-

legal considerations. Fax a completed Post-Op Exam form to the MD’s oﬃce following each

patient visit. Should you have any questions, do not hesitate to call the surgeon. Contact the surgeon

immediately if any complication arises. Please note that Visit and Medication schedule may vary by

surgeon and patient. Please consult with the surgeon for each patient.

Sample Patient:

Visit Examination Description

Day 0 Patient undergoes surgery.

Day 1 Examination by Surgeon or Co-Managing PECP as predetermined.

Days 2-20 Patient remains under care of Surgeon. Patient may have no

cheduled visits, but may see Surgeon as needed.

Days 21-90 PECP takes over care of ﬁrst eye. Complete “Post-op Exam Form”

d fax to surgeon following each visit.

Day 30 Examination by Co-Managing Doctor. Refraction and Evaluation of

d eye. 2nd eye referral to Surgeon if needed.

3 months, 6 months, 1 year Multifocal or upgraded lens patients only: Examination and

efraction by Co-Managing Doctor.

On each exam, the following observations need to be recorded on a post-op form and faxed to the

urgeon’s oﬃce:

• Vision, without correction and through a pinhole. Intermediate and near VA for

presbyopia correcting IOL

• Consider Keratometric readings

• Slit lamp exam

• Intraocular pressure (call us if the IOP is above 25 mm Hg.)

• Refraction status w/visual acuity and near vision at 1 week, 1 month, and beyond for

prebyopia correcting and toric IOLs

• Review post-operative medications and prescribe as appropriate

COLA Cataract & Implant Co-Management Policy and Procedure Manual

Page 18

Cataract/Implant Post-Operative Form

Surgeon _________________________________________________ Date ______________________

Patient’s Name _________________________________________________ q OD q OS q OU

Surgery Date __________________

Co-Managing Doctor ____________________________________

Follow-up Date ________________

Had Surgery at (city) ____________________________________

Procedure q Phakic IOL q Toric q Wavefront Analysis

q Accommodating q Multifocal q ICL q Other ______________________

q 1 Day q 1 Week q 1 Month q 3 Months q 6 Months

Other OD ______________________________ OS ______________________________

(Include slit lamp and dilated fundus as needed.) Current Meds _____________________________________

Subjective Findings ___________________________________________________________________________

___________________________________________________________________________________________

Assessment OD OS

VA sc D 20/_____ I 20/ _____ Near _____ D 20/_____ I 20/ _____ Near _____

Refraction ______________________ 20/ _____ ______________________ 20/ _____

Keratometry

(auto/manual) __________ / ___________ @ _______ ___________ / ___________ @ _______

Lens

q Clear Other __________

_______________

q Clear Other __________

_______________

Intraocular Pressure

circle:

NCT / Goldman / Tonopen _________________ mm/Hg _________________ mm/Hg

Impression on presbyopia correction _____________________________________________________________

Impression/comments ________________________________________________________________________

Plan _______________________________________________________________________________________

Next planned visit _________________

Doctor’s Agreement: I accept medical and legal responsibility for this patient’s post-operative surgical care.

I have explained this co-management arrangement with the patient and he/she understands that he/she may

contact the surgeon at any time.

Doctor Signature _____________________________________________

Please Fax Completed Form to Surgeon

PHAKIC IOL • REFRACTIVE IOL

Payment Authorization and Procedure Information

PATIENT INFORMATION

NAME (Last Name, First Name, Middle Initial) DATE OF BIRTH (Month/Day/Year) GENDER

q Female q Male

ADDRESS (Street) LAST FOUR DIGITS OF SSN DOES PATIENT NEED A RECEIPT?

q Yes q No

CITY HOME PHONE

( )

STATE ZIP WORK PHONE

( )

SURGERY INFORMATION

SURGERY DATE (Month/Date/Year) EYES

q OD q OS q OU

PROCEDURE

q Phakic IOL q Toric q Wavefront Analysis

q Presbyopia-correcting (accommodating, multifocal)

q Accommodating IOL (Crystalens, ReStor, ReZoom)

q Clear Lensectomy q Other _______________________

This payment represents: q Entire Global Fee q Prof. Fee Only

Collection of Fee: q OD q Surgery Center

SURGERY CENTER

PECP

SURGEON

PAYMENT INFORMATION

TOTAL FEE CREDIT/DEBIT CARDS

q VISA/MC $__________ q AMEX $__________

q Discover $__________ q Other $__________

__________-__________-__________-__________ _______

Card Number Exp. Date

I understand that a hold will be placed on my account for the amount indicated

above. The hold will be removed if the procedure is cancelled, or the surgeon

elects to postpone surgery for medical reasons.

________________________________________ __________

Cardholder Signature Date

Please note: Most banks place daily spending limits on debit cards. Please

check with your bank before your procedure.

FINANCING

Please contact the

COLA ofce at

510-895-9657

PROF. FEE ONLY

IOL ONLY

CASH/CHECK

q Cash $____________

q Check $___________

Payment must be received

one week prior to surgery.

COMMENTS

_______________________________________________________________________________________________________

I have elected to have refractive correction surgery at a surgery center contracting with the COLA Medical Corporation. I request that my pre-operative and

follow-up care be done by my primary eye care provider (PECP). I agree to have refractive surgery done by the Surgeon contracting with COLA Medical

Corporation whose name is listed above. I understand that the Surgeon and my PECP are independent practitioners who cooperate for the purpose of

providing continuity of patient care. Both doctors and the facility will receive separate payment for their services.

I understand that the basic intraocular lens procedure is paid for by Medicare and each doctor and the facility will bill Medicare independently. However

certain services related to the premium intraocular lens I will receive are not covered by Medicare,

I understand that COLA will coordinate payment for the non-Medicare covered services. I choose to make one Global Fee payment as listed above to COLA

with the understanding that it will distribute payment to my Surgeon, my PECP

and the facility as specied under the COLA Medical Corporation contracts.

Patient Signature _______________________________________________________________ Date ______________________________

Form Completed By Date Mail/Fax

Faxed to COLA 510-895-9680: Date____________ Initials ________ Copy to Patient: Date____________ Initials ________

P.O. Box 1328

Santa Clara, CA 95052-1328

PH: 510-895-9657 Fax: 510-895-9680

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