Should You Add Glaucoma?


The specialty might be a viable option if you're looking to augment your cataract caseload.

While cataract procedures will continue to fuel your center's ophthalmic engines, glaucoma surgery may inject some life into a sputtering case mix. Thanks to some positive shifts in Medicare reimbursements, adding laser trabeculoplasty and trabeculectomy will increase profits and make your facility a convenient place for surgeons already bringing cataract cases to your ORs.

Reimbursement review
Medicated eye drops are the first-line treatment for glaucoma. When drops fail to adequately lower intraocular pressure, surgical interventions manage the problem. My facility hosts three commonly performed procedures: laser trabeculoplasty, trabeculectomy and implantation of glaucoma drainage implants (see "Glaucoma 101").

Thanks to continued improvements in pharmaceutical treatments, it's unreasonable to expect or rely on a high volume of glaucoma cases to justify adding the service line. The opportunity for financial success still exists, however, for administrators who are able to control supply costs, navigate the current reimbursement landscape and capitalize on commercial payor cases.

  • Laser trabeculoplasty. CPT 65855 was added to the list of Medicare-approved ASC procedures in 2008, with reimbursement set at $132.53.
  • Trabeculectomy and glaucoma drainage implants. Medicare reimbursement for trabeculectomy has increased marginally after implementation of the new ASC payment system. Payment for trabeculectomy ab externo (CPT 66170) is currently $712. That payment will increase to $959.50 when the new system's rates are fully implemented in 2011. Reimbursement for aqueous shunt to extraocular reservoir (CPT 66180) is currently $949, with a bump to $1,644 expected by 2011. Keep in mind that Medicare's new payment system no longer reimburses for the cost of eye implants. Current rates are too low to cover the additional implant expense, so you may have to wait until 2011 to earn a profit from Medicare trabeculectomy cases.

Commercial payors vary in their trabeculectomy reimbursement rates. With expert negotiating, implant precertification, carveouts and accurate coding, profits can be had. Let's crunch the numbers on an Ahmed valve drainage implant recently performed at our facility. We were reimbursed $1,375 for the procedure (CPT 66180) and $1,375 for the valve (L8612). The valve cost $595, a pericardium patch graft used in the case ran us $275 and other miscellaneous supplies (including suture, pack, gloves and gown) totaled $100. That's a total case cost of around $970.

We netted around $1,780 after receiving the facility fee and implant reimbursement from the commercial payor. Our typical per-case profit is slightly less, however. You can realistically expect to receive $1,100 for the procedure and $600 for the valve for a $730 per-case profit. We would have essentially broken even if we performed the same procedure on a Medicare patient, thanks to CMS's current $949 reimbursement rate for trabeculectomy with device implantation.

Minor adjustments
Cataract cases are usually routine procedures, often performed in less than 15 minutes, which thrive on factory-like efficiency. Expect the slightly more complicated trabeculectomy procedures to last between 30 and 40 minutes. Schedule the cases at the beginning or end of the surgical day to avoid disrupting cataract's crucial clinical flow.

Facilities outfitted for cataract cases require little additional equipment and supplies for adding trabeculectomy procedures. You may need to purchase scissors designed for cutting the eye's conjunctiva, specialized suture that helps create a watertight sclera flap, a sclera punch, pericardium patch grafts and instrumentation for performing an iridectomy.

Work with your surgeons to educate staff about current glaucoma treatment options. Our glaucoma surgeon, Gary Belen, MD, reviewed the basics of laser trabeculoplasty and trabeculectomy and provided a detailed look at how the procedures are performed, the clinical goals of each, potential complications and the roles our clinical teams would play in the operating room. His presentation was a major factor in our staff's successfully learning new clinical skills and patient care protocols.

The biggest adjustments we've had to make pertain to the physical and mental condition of glaucoma patients. While cataract patients are typically healthy individuals with expectations of quick and easy procedures, some acute angle closure glaucoma patients present in extreme discomfort. These patients will come to your center because first-line medication treatments have failed to manage high intraocular pressure that can cause headaches and nausea. Glaucoma patients deserve extra attention from your staff. In the end, a little TLC and empathy for their condition may be all it takes to make them as comfortable as possible while in your care.

Glaucoma 101

Here are terms your staff should be familiar with before you add glaucoma cases.

• Laser trabeculoplasty. Selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT) take a few minutes. Both target the trabecular meshwork to reduce fluid outflow and facilitate improved aqueous fluid drainage. The difference between the procedures lies in the laser's function. Traditional argon lasers can damage the drainage area, limiting treatment to 180-degree increments of the eye per session. SLT employs a cold laser that doesn't damage the eye's tissue, letting surgeons treat more of the eye during a single procedure. SLT has clear clinical advantages over ALT, but the laser costs around $60,000. Laser trabeculoplasty is done in a non-sterile procedure room. Patients are prepped with anesthetic eye drops and leave the facility soon after the procedure with little to no ill effects.

• Trabeculectomy. Filtration surgery, the gold standard of glaucoma surgery, is best suited for patients with more advanced forms of the condition that are unresponsive to medications or laser treatments. The procedure filters excess aqueous fluid from inside the eye, where it causes damage to the optic nerve, to the eye's outer surface. Surgeons cut a small hole in the sclera that remains partially covered by a tissue flap. Aqueous fluid drains from the inner eye through the opening in the sclera and forms a bubble, or bleb, on the sclera flap. The pooled fluid is then absorbed into the bloodstream. Patients are prepped with peribulbar or retrobulbar anesthesia. They're given antibiotic, anti-inflammatory and pilocarpine drops. While requiring a more delicate touch around the surgical site as compared to cataract surgery, trabeculectomy is routine for skilled surgeons. The post-op care is more involved, however. Potential complications include scarring around the sclera flap, bleb leaks and post-op infections, including endophthalmitis.

• Glaucoma drainage implants. These silicone implants, inserted into the back of the eye, collect and release aqueous fluid from the inner eye. The three most commonly used devices are Baerveldt, Molteno and Ahmed implants. They're used to treat intractable glaucoma, and neovascular or inflammatory glaucoma, two conditions that increase the risk of bleb scarring.

Recent debate has centered on the efficacy of glaucoma drainage implants and their possible use as a surgical first-line treatment of glaucoma. The implants have been shown to lessen post-op complication risks and often match the effectiveness of conventional trabeculectomy in lowering IOP. They demand extreme precision and manipulation of delicate instruments around the eye. A skilled surgical tech must learn to delicately grasp the conjunctiva without tearing it, cut suture and wipe the surgical site during surgery without disrupting the surgeon, among other clinical skills.

• Canaloplasty. During this non-penetrating procedure, surgeons widen Schlemm's canal to allow for increased aqueous fluid drainage. That's accomplished with an injection of viscoelastic into the canal or cannulation of the canal with suture.

Canaloplasty lowers IOP, but usually not as far as trabeculectomy. Because it is a non-penetrating procedure, it results in a lower incidence of endophthalmitis and fewer overall post-op complications when compared to trabeculectomy. The procedure shows tremendous promise, especially for surgeons hungry for a new glaucoma treatment option.

— Gary Belen, MD

Dr. Belen ([email protected]) performs cataract and glaucoma surgery at Madison Street Surgery Center in Denver, Colo.

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