The acute need for remote patient management as a result of the COVID-19 pandemic catapulted telemedicine and adjunct technology to the forefront of medicine. Consequently, this method of delivering care has become a larger part of everyday practice. This article will provide considerations to safely and effectively deliver patient care via telemedicine, specifically regarding contact lens patients. We will review some of the literature on telemedicine for corneal pathology and contact lenses, provide anecdotal recommendations, discuss limitations, briefly mention objective image analytics and artificial intelligence, and finally, outline billing and coding.

GENERAL PRINCIPLES

Melvin Kranzberg’s Laws of Technology contains the famous statement: “Technology is neither good nor bad, nor is it neutral.”¹ Many principles in this famous document still apply today. It is all about the application of the technology, and we as practitioners should keep this in mind. Remember, telemedicine is simply another method of delivering the care that practitioners have always provided, but they must remain aware of the limitations, the largest of which are the patients themselves and the possible complications and repercussions. The best practice is to provide hybrid care, with an emphasis on primary physical in-office care and part telemedicine as an adjunct to in-office care.

Types of Telemedicine Communication There are two main classifications of telemedicine communication: synchronous and asynchronous. Synchronous refers to “live” or “real-time” video communication between practitioner and patient. Asynchronous communication refers to submitting photos, video, testing, questionnaires, etc., from patients to their practitioner for evaluation without live interaction.

THE COVID-19 EXPERIENCE

Since the COVID-19 pandemic began, many publications have reported on its impact on clinical practice. Five hundred eyecare providers, the vast majority of whom were optometrists, were polled about aspects of telemedicine practice.² This survey reported that in January 2021, 44% of respondents were using telemedicine in clinical practice. Of those using telemedicine, 69% were using it for virtual visits with patients at home, 26% were using telemedicine for contact lens follow ups, 28% reported that they would like to use it for contact lens follow ups, 23% reported that they would need to learn more prior to implementing telemedicine for contact lens follow up, and 23% reported that they were not inclined to use telemedicine for this purpose. For those not using telemedicine, 31% would like to use it for contact lens follow up, and 21% would like to use it for virtual visits with patients at home.²

One of the earliest papers published (after the start of the pandemic) about telehealth and contact lens services offered an excellent literature review on what was known and unknown about telemedicine services and their application to contact lenses.³ It touched on the lack of data about self-administered testing and imaging. During the pandemic, a set of instructions to guide self-administered imaging and video has been developed.⁴ This document is free for practitioners to download on the Scleral Lens Education Society’s website and was distributed through several social media channels. The video instructions are available on YouTube.⁵

TELEMEDICINE IN THE CONTACT LENS PRACTICE

Minimal articles on the use of telemedicine for contact lenses, especially specialty contact lenses for the management of disease, have been published. A series of PubMed queries using a combination of the keywords telemedicine, telehealth, remote care, remote examination, remote evaluation, contact lens, and contact lenses provided few relevant results as of June 27, 2021. This article will share experiences and lessons learned from using telemedicine in managing irregular corneas and ocular surface disease with various specialty contact lenses.

Telemedicine can be beneficial when used in managing a variety of anterior ocular conditions. It allows practitioners to perform gross assessment, which can be vital in triaging a patient’s eye condition. It can also help monitor patients and improve patient compliance. For example, patients may send photos of their eyes a few days after initiating a treatment as a progress evaluation. This was particularly useful when social distancing was required during the COVID-19 pandemic. However, if advanced diagnostic imaging is required, adjunct devices and an in-office visit are necessary.

There is published literature on fitting GP lenses via asynchronous video evaluation.⁶ It showed that 80% of fits performed virtually agreed with live in-office fittings (with 67% agreement on refit parameters), which is astounding considering that this was published in 2001! In the next sections, we will look at the challenges and limitations specific to telemedicine and contact lenses.

GENERAL TELEMEDICINE LIMITATIONS

The limitations of telemedicine are different based on the location of the patient and on the technology available for examination. This could include a patient at home with only a smartphone versus a patient in a medical facility or in a mobile clinic that has certified medical staff and advanced diagnostics to aid in examination with an off-site provider. All practitioners should understand the limitations of telemedicine and that cases must be physically examined when a confident diagnosis and treatment plan cannot be established.

PATIENT AT-HOME EVALUATION

Contact Lens Follow-Up Assessment Generally, the best way to perform a contact lens follow-up telemedicine visit is to collect asynchronous images, video, and history and then follow up with a brief synchronous visit. Collecting asynchronous information first can be compared to a chart review before entering an examination room, allowing you to review the history and available data. The synchronous visit is similar to the interaction with patients once in the room, which can enable you to assess a patient’s demeanor, confirm issues by live examination, and communicate the plan and the importance of follow up directly to the patient.

During a contact lens follow-up examination, four specific assessments are needed: 1) patient history, 2) vision assessment, 3) contact lens examination, and 4) ocular surface evaluation.

The patient history can be obtained with a series of intake questions. A symptom questionnaire can evaluate anterior eye health, the most important pertaining to symptoms of eye pain, glare, redness, and blurred vision to indicate anterior segment disease.⁷ In tandem with the questionnaire, it is important to include directions on obtaining vital information such as visual acuity, images, and video. The first tests needed are visual acuity and an over-refraction. Many systems have been researched, and several validated, for smartphone, augmented reality, and web-based visual acuity, contrast sensitivity, and refraction evaluation.^8-12

Following vision is the slit lamp examination. An assessment of the eye while lenses are worn and of the ocular surface health after lens removal—undoubtedly the most important parts of a contact lens follow up—are required. Today’s smart devices are capable of visualizing contact lenses, especially scleral lenses, with ease. However, this assumes that patients can capture photos and videos adequately for practitioners to evaluate accurately. When patients are at home, good instructions are a must, as the quality of the images provided will determine the ability to evaluate the lens and ocular surface. A basic understanding of a patient’s imaging device can yield a sense of the image quality that you might receive. Megapixel resolution is essential; if megapixels are high, zoom is less critical compared to a focused image.

Today’s devices, without attachments, can produce only the equivalent of a monocular view with diffuse white light. Though gross observation of the eye is possible, several critical evaluations are difficult to perform due to the lack of several elements—some of the most important being vital dyes, different color illuminations, and lighting techniques. Shadows, edema, conjunctival injection, and vessel compression or engorgement are helpful non-specific indicators of complications or the need for lens modification.

During lens-on evaluations of a variety of lenses and patients, including images in different gazes, with and without the lids being held as well as with video recording different gazes and blinking, we found assessment of lens movement and centration very easy. Identification of haptic alignment was simple; we found vessel compression easy to identify. Edge lift was more difficult to discern (Figure 1). However, corneal clearance, alignment, or bearing could not be assessed.

Once the lens was removed from the eye, hyperemia and conjunctival compression were good indicators of misalignment, especially when a pattern such as horizontal or vertical injection was present. The ocular surface condition, especially corneal epithelial integrity, could not be easily ascertained. However, we could identify subtle corneal scars, graft-host junctions, and even laser-assisted in situ keratomileusis (LASIK) flaps. Proper eversion of lids with adequate imaging was nearly impossible. Synchronous communication offered an ideal opportunity to review contact lens solutions with visual confirmation as well as to observe and to reinforce techniques for lens application and removal.

Systems for objective image analysis are available, but these are only useful if the quality of the images is adequate. One study reported that images from an iTouch 5S showed low sensitivity to detect corneal pathology such as corneal abrasions, ulcers, scars, and pterygia;¹³ however, this imaging technology is seven generations old. In our experience, newer devices are capable of much more detailed evaluations.

Limitations include patients’ ability to perform self-examination and to follow directions, lack of access to a stable high-speed internet connection, inadequate camera resolution, and non-medically-trained physical examination. Live video assessment can be helpful, as the ability to guide an evaluation may increase success. Although these limitations exist, many can be overcome by means such as having a family member, caretaker, or friend aid in image capture. The most significant limitation is the patients themselves. Collectively, we found several instances in which images and videos were simply inadequate to evaluate (Figure 2). We all noted that having patients’ established history was extremely helpful in understanding what complications to look for and what quality of vision we should be expecting.

Triage of conditions was quite good; one evaluation led to the diagnosis of early graft rejection in which treatment was initiated and the patient was later evaluated in-office for confirmation. One less successful evaluation occurred in which a patient who was experiencing foreign body sensation after a soft lens tore on-eye sent poor images and video; the synchronous video call was poor quality due to an insufficient connection and to poor corroboration. The patient was directed to come in for an emergency evaluation but refused. A few hours after the evaluation, the patient blinked out the lens fragment. In the literature, telemedicine triage proved safe and effective; the hybrid model was favored during the pandemic, and it was proposed that when used for anterior segment disease, it could alleviate overburdened healthcare systems.^14,15

At-Home Devices With the development of devices that allow patients to monitor their ocular conditions such as intraocular pressure and macular degeneration, the ability to perform highly sophisticated testing at home has become a reality. Devices like these allow many more data points to be collected at more frequent intervals to better understand the individuals’ disease status. Regular monitoring will also aid in early diagnosis and early intervention. In specialty contact lenses, specialized home monitoring devices will be developed as part of the comprehensive management of specific disease states. We may see devices designed to monitor myopia, ectasia, or ocular surface diseases, which will fill the gap between in-office visits.

However, there is currently no peer-reviewed literature suggesting that online sources are a viable way of updating contact lens prescription criteria.

PATIENT IN-OFFICE, PRACTITIONER REMOTE

Peer-to-Peer, Satellite Offices, and Drone Technology One of the many challenges and criticisms of telemedicine is the lack of in-depth evaluations. However, many of these challenges can be overcome if you apply technology. Generally, in traditional evaluations, a practitioner uses observational skills to raise suspicion, then orders in-depth diagnostic testing to confirm a diagnosis. This process can be turned around so that the in-depth testing is performed first, followed by confirmation by the practitioner. As technologies have become more advanced, miniaturized, combined into single devices, and have more sophisticated ways of determining whether data collected is erroneous, this workflow has become more of a reality—i.e., using cutting-edge technology as a screening tool. If you can obtain a scan, you can evaluate. However, you will need trained medical staff (including certified ophthalmic technicians and medical technicians) to run the imaging system and to guide patients through the evaluation. The limitation is now in the data transfer, and all scans and examination data can be uploaded to a cloud-based electronic medical records (EMR) system for off-site practitioner review. After review, communication can be established between practitioner and patient via video call.

Any device that has an internet connection can be accessed remotely. This includes instrumentation such as digital phoropters. But what about a slit lamp exam? Can this be performed? A recent study reviewed the use of slit lamp videos for pediatric anterior segment telemedicine consultation and reported high sensitivity and specificity for conjunctiva, sclera, anterior chamber, iris, lens, and cornea findings, with moderate sensitivity (but high specificity) for eyelid and lash pathology.¹⁶

The use of binocular remote-controlled slit lamps, referred to as “drone slit lamps,” has been explored. These allow an off-site practitioner to control a slit lamp while using a virtual reality headset or monitor with 3D glasses to obtain a live view. There is significant agreement between the drone and conventional slit lamp evaluation when assessing anterior chamber depth, cells, and flare, demonstrating 88.2% to 100% specificity and sensitivity when compared.¹⁷ One of the criticisms of live remote evaluation is lag—the time delay between physical and digital movement (such as a person moving “in real life” versus the representation of the movement on video footage during synchronous evaluation). However, with low-latency connections such as cellular 5G data connections, this is significantly less of a concern.¹⁸ Remote surgeries are being studied with such technology.^19,20 Applying this to specialty contact lenses, with growth in the area of scan-based empirical lens design, a first lens can be designed based on the data versus a diagnostic contact lens fitting.

Objective Image Analytics and Artificial Intelligence Objective image analytics (OIA) is the use of software to selectively analyze an image or video (a sequential series of images) for the purposes of quantification with increased levels of repeatability, while reducing intra- and inter-practitioner variability. OIA is not new; Image J has been available from the National Institutes of Health (NIH) for nearly 25 years, and multiple device-specific OIA software applications are able to analyze the anterior eye. However, there are few agnostic options, which is where there is a need for the current state of patient-to-practitioner asynchronous telemedicine. Agnostic OIA software has been used to measure bulbar conjunctival injection and superficial punctate staining as well as to analyze the movement of contact lenses and the size of corneal ulcers.^21-24

Artificial intelligence (AI) leverages OIA by then taking the next steps to incorporate multiple metrics to detect and grade a disease state. Currently, there are AI systems approved by the U.S. Food and Drug Administration (FDA) for posterior segment disease detection.²⁵ At this time, there are no FDA-approved anterior segment AI systems; however, good work is being performed. For example, one study on screening for Descemet’s Membrane Endothelial Keratoplasty (DMEK) detachments showed that an AI system could identify the detachment with 96% accuracy in 100 ultra-high-definition optical coherence tomography (UHD OCT) images.²⁶ Another study showed that AI could correctly identify fungal keratitis 99.95% of the time in 1,200 confocal microscopy images.²⁷ Many studies have been performed on AI-detection of keratoconus, and one standout showed 99.6% accuracy in detection with 20,000 anterior segment OCT images!²⁸ Many other studies have been published, including screening for iris tumors, cataract grading, and even intraocular lens calculations.²⁹

And, while there have been only a few studies published on AI for contact lenses, such as for first lens selection in orthokeratology and for designing GP lenses and evaluation of GP lens movement (both for keratoconus),^11,30-32 it’s not difficult to imagine future potential applications. Some practitioners fear the use of Al; however, AI is constantly being used in the context of clinical practice every day, from comparative data on optic nerve fiber layer thickness with OCT to corneal ectasia screening with corneal tomography. The application to telemedicine will be the next frontier.

CODING AND BILLING FOR TELEHEALTH?

One of the most critical elements of using telehealth in your practice is receiving payment for the services that you render. Only under certain circumstances would you consider setting up a clinic in which your face-to-face visits were performed for free. It makes no sense to do the same for telehealth.

Before the pandemic, it was nearly impossible to get paid for telehealth visits because the U.S. Department of Health and Human Services (HMS) had designated the newly established Current Procedural Terminology (CPT) Codes for telehealth to be non-covered services. What HMS does in payment policy gives private payors the cover to deny the same.

However, when the pandemic demanded strict mitigation measures, patients had limited access to their practitioners because of state mandates. So, HMS, through the Centers for Medicare and Medicaid Services (CMS), issued a policy change that reclassified telehealth services as covered services. This policy can be found at: “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” (42 CFR Parts 400, 405, 409, 410, 412, 414, 415, 417, 418, 421, 422, 423, 425, 440, 482, and 510 [CMS-1744-IFC] {RIN 0938-AU31}).

CMS had already begun to move in that direction in 2019 in the Final Rule, “Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services” (CMS 1693-p). The final puzzle piece was a blessing from the HHS Office of Civil Rights (CMS OCR) regarding health privacy and telehealth, found at: “HIPAA Administrative Simplification Regulations” (45 CFR Parts 160, 162, and 164).

With the regulatory framework in place, let’s examine the codes. In spring 2019, HHS, through the American Medical Association (AMA) CPT Edit Committee, promulgated new codes for telemedicine/telehealth. These CPT codes and the Healthcare Common Procedure Coding System (HCPCS) codes that were already established are listed in Table 1.

Using the –95 Modifier (Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications systems) and following the Evaluation and Management (E/M) Level Choice Rubric in the E/M Preamble is an easy way to go that is less confusing. During the pandemic, using the –95 Modifier is optional, but I highly recommend using it anyway to protect you during an audit.

You cannot use the –95 Modifier while doing peer-to-peer telehealth. Also, as the 99211 code is for staff only, you cannot use the –95 Modifier for that code either.

Under an 1135 waiver titled “A Declaration of Emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act),” certain types of technologies that will not be allowed once the pandemic is over are allowed now. HIPAA Compliant Platform Requirements are waived, as HHS OCR will not penalize a practitioner as long as the platform is not used in a public-facing manner. Allowed platforms include Apple FaceTime, Facebook Messenger text and video, WhatsApp, Skype, Jabber, and iMessenger EHR. Not permitted, even during the pandemic, are Facebook Live, Twitch, and Tik-Tok.

Finally, reimbursement rates will be the same for telehealth as they are for outpatient services. General Ophthalmological CPT Codes do not qualify as covered services for telehealth—use the above referenced CPT and HCPCS codes only. New patients can be seen under this waiver, as HHS will not audit for new versus established. The latest information can be found at www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf .

CONCLUSION

To revisit Kranzberg,¹ “Technology’s interaction with the social ecology is such that technical developments frequently have environmental, social, and human consequences that go far beyond the immediate purposes of the technical devices and practices themselves, and technology can have quite different results when introduced into different contexts or under different circumstances.” In this case, under emergency use as the result of the pandemic, telemedicine can be a great adjunct to current care; however, practitioners must remain cognizant of the limitations regardless of whether they embrace telemedicine fully, partially, or not at all. CLS

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