The Business of Contact Lenses

Working with Complex Patients

BY CLARKE D. NEWMAN, OD, FAAO

Those of us who work in medically necessary contact lens prescribing often encounter patients who have complicated medical histories and who frequently have many things wrong with them at the same time. Are you prepared to handle such cases?

Is your office set up to address the needs of those rare patients who present with a case complicated enough to warrant an Evaluation and Management (E/M) Level 5 visit? This question covers everything from patient scheduling and insurance processing to case history, review of systems management, and examining the patient to obtaining the proper documentary evidence to support medical necessity for ordering a wide array of ancillary tests that would support that level of complexity.

Initial Considerations

Is your schedule adaptable? Do you have the time capacity to spend an hour with a new complex patient case? Is your staff sensitive to the needs and demands of this type of patient and how seeing this type of patient might affect the patient flow in the office? Does your staff see these complex cases and proactively reach out to previous eyecare professionals for records that might be helpful prior to scheduling such patients?

In my office, we have a Patient Pending file where we reposit all records forwarded from referring and consulting doctors regarding new patients whom we might not see for months. This type of protocol is not complicated, but it demonstrates that you have given some forethought to the possibility that you might get such a patient.

Does your office have the necessary equipment to examine a complex patient in a manner that is consistent with the standard of care? With medically necessary contact lens patients, that might mean having the latest topographer, specular microscope, aberrometer, coherence tomographer, or visual field instrument. It also means having a wide array of diagnostic lenses and the expertise to handle them.

Working with Colleagues

Seeing such a patient sometimes requires you to take ownership of managing the patient’s condition beyond the mere prescribing of a contact lens. If you’ve ever prescribed for Stevens-Johnson syndrome or graft-versus-host disease, you know what I mean.

You have to be able to work in an interdisciplinary manner with other physicians. Maintaining a steady flow of professional communication with them is essential to providing the standard of care to these patients. You have to know what case history complexities go into justifying an E/M Level 5 visit, and then decide whether that type of history is medically necessary.

A Recent Case

We recently saw a 15-year-old male with a history of congenital optic nerve hypoplasia, aniridia, nystagmus, strabismus, micro cornea, and lenticular abnormalities. You might think that there isn’t much to do for someone like that, but this child was in every other way a normal kid who was thriving in school.

He presented to me upon a referral from his strabismus surgeon in Ohio for a scleral lens piggybacked over an iris imprint lens.

First, we had to obtain files from the referring doctor. Second, we had to schedule the patient in a time slot that would absorb a time over-run.

Next, we had to complete a very thorough case history and review of systems. This interview hinges on determining the chief complaint.

Knowing why these complex patients are there and what they expect from you is essential to their care. If you and your office are prepared ahead of time, your practice will be able to help patients such as these. CLS

Dr. Newman has been in private practice in Dallas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a Diplomate in the AAO and a consultant to B+L, AMO, and Alden Optical. Contact him at cdnewman@earthlink.net.