At A Glance

  • In the COVID-19 era, patients appreciate the ability of eye care providers to remotely address their problems.
  • Knowing that telemedicine technology in eye care is only going to improve, we must consider how we can implement it into our practices now to be ready for the future.
  • Virtual care provides a chance to strengthen our relationships with existing patients and to develop new ones.

In just a few short months, telemedicine has become a vital service offering for our patients and our practices. Although telemedicine has been around for years, the COVID-19 pandemic was the tipping point for eye care providers to embrace the technology. Telemedicine has given us the ability to connect with our patients and colleagues to provide accessible and timely care in a convenient, socially distanced manner.

Now that eye care is reopening and we are all ramping up our practices, some questions remain. What opportunities will exist for telemedicine in our future practice initiatives? Will we let it fade away, or will we take it to the next level?

THE FUTURE IS NOW

With telemedicine, as with many factors in life, we can choose to either take a reactive or proactive approach. No matter the approach, however, telemedicine is not going to wait for us to decide. Our ability to provide eye care remotely through problem-focused exams is something that patients appreciate. Although the technology may now be limited in scope, we must look toward future possibilities for optimizing patient health.

Deep learning and artificial intelligence (AI) may seem to be concepts of the distant future, but they are already here. Consider the IDx-Dr (IDx Technologies), an AI technology capable of detecting more than mild diabetic retinopathy with high sensitivity (87%) and specificity (90%). Or consider the AI software Pegasus (VisuLytix), which can detect glaucomatous optic neuropathy with an accuracy of 83.4%—compared with ophthalmologists and optometrists at 80.5% and 80%, respectively.1,2

These technologies will enable doctors to provide care in a more efficient manner, thus allowing more patients to be seen. Although they are not yet available on the market, these technologies and others like them will surely play a role in the future of eye care and telemedicine.

Knowing that telemedicine technology in eye care is only going to improve, we must consider now how we can implement it into our practices to be ready for the future. Many of us have dabbled in telemedicine, and some have had more success than others. Imagine if we fully commit to implementing it into our practices and have it available to complement our in-person services.

NEW WAYS TO CARE

In our new socially distanced world, we need to continually reinvent ourselves and our practices to find new ways to care for our existing patients while attracting new ones and establishing new income streams. Failure to embrace telemedicine’s benefits may allow other entities to remove certain aspects of practice from our control.

The following are a few ideas for incorporating telemedicine into our practices in ways that allow us to bill for the services (see also Coding Tips and Coding Cautions).

CODING TIPS

CPT codes 99421–99423 may be used in place of face-to-face E/M visit codes. These codes require use of a HIPAA-compliant synchronous real-time audio-video communication platform. They may not be used for postoperative care or reporting of test results. An example of proper use of these codes would be to remotely evaluate a patient who contacts you regarding a stye, allergy-related ocular problems, or acute problems related to contact lens wear.

CPT codes 99446–99449 and 99451 may be used by the consulting doctor for evaluating patient information or images sent by the treating physician and discussing recommendations for testing or treatment with the treating physician. CPT code 99452 is used by the treating or referring physician requesting the consult. Examples would be sending a patient’s retinal images to a retina specialist for guidance in diagnosis or treatment, or discussing visual field and OCT results with a glaucoma specialist.

CPT code 92227 can be billed for the analysis and report when remote imaging is done for the detection of retinal disease such as is being done in many primary care physicians’ offices for patients with diabetes. CPT code 92228 can be billed for the interpretation and report when remote imaging is done for patients with active retinal disease.

Virtual check-in codes are relatively new telemedicine codes. Virtual check-ins may be done using either synchronous or asynchronous (text, email) communication methods.

Code G2010 may be used when a patient sends a picture of an ocular condition (store and forward) and the doctor reports his or her interpretation to the patient via one of several possible communication methods.

Code G2012 may be used when brief progress check visits are conducted with dry eye patients or patients who were seen in office for an E/M visit, as long as the televisit occurs more than 7 days after the E/M visit.

CODING CAUTIONS

Important points for any eye care practitioner using telemedicine to keep in mind.

  • Always get either verbal or written permission from the patient for both conducting and billing for a telemedicine visit
  • The codes specified in Coding Tips were in effect prior to the COVID-19 public health emergency (PHE), and the requirements for use, reimbursement, and use of modifiers and place-of-service codes may change. Remember that, if a telemedicine visit results in a patient being scheduled for an in-office E/M visit within 24 hours or for the soonest available appointment, the telemedicine code may not be billed
  • The emergency regulations enacted under the COVID-19 PHE have allowed the use of non–HIPAA-compliant synchronous platforms such as FaceTime and Skype. The assumption is that synchronous communication will revert to only HIPAA-compliant platforms after the PHE period ends
  • The information provided here applies only to CMS-related insurance plans. Private carriers may or may not accept these codes and may have their own carrier-specific criteria for their use and billing

Emergencies/Urgencies

Many anterior segment conditions don’t necessarily have to be seen in the office and can be addressed via telemedicine.

Interprofessional Consultations

Phone consults with other providers allow us to get opinions on our patients’ conditions or interpretations of tests and images. Although not yet in common use, interprofessional codes are available that both referring and consulting doctors can use to bill for care provided for the benefit of the patient and be reimbursed for their time and expertise.

Diabetes Care

Many primary care physicians are using telemedicine for patients with diabetes and sending fundus photos to a reading center to screen for diabetic retinopathy. Whether you provide the interpretation or you send the image to a reading center, the image is only one part of the examination. Many patients still need a referral for detected diabetic retinopathy, glaucoma, or other ocular conditions such as decreased vision, glaucoma, etc.

Contact Lens Follow-Ups

After initial fittings, we can use telemedicine to follow up with contact lens patients. Communicating with our patients in this way, we can help ensure a successful fit, address questions and concerns, and perform a gross evaluation of the contact lens fit. These services would likely be included in the global fee for the initial evaluation, fitting, and progress check for new contact lens patients or new contact lens designs for established patients. Established contact lens wearers with acute problems could be evaluated using codes 99421-99423, as explained in Coding Tips.

Dry Eye Disease Monitoring

Telemedicine can be used to care for both new and existing patients with dry eye. We are advocates for point-of-care testing, which obviously cannot be performed during a virtual visit. Nonetheless, we can still obtain a history, review medical history, discuss previous treatments, and initiate therapy. A common scenario in which telemedicine can be used is in virtual follow-ups. There are many effective and safe medications available for our dry eye patients, and we can prescribe as indicated and follow-up 4 to 6 weeks later to check on their progress using questionnaires such as the Standard Patient Evaluation of Eye Dryness or the Ocular Surface Disease Index.

Glaucoma and Retina Considerations

Telemedicine can be used for some diagnostic testing services for chronic disease management. For some follow-ups, patients can be scheduled to come to the office for testing only (OCT, visual fields, IOP checks, dark adaptation, electrodiagnostics, etc.). This type of hybrid evaluation minimizes the amount of time the patient is in the clinic. The patient can then later have a scheduled telemedicine visit to discuss treatment and management considerations. Another option for glaucoma care is the Icare Home (Icare USA) tonometer. Patients can either buy or rent this device to take daily IOP measurements at home. There are also visual field options for at-home use in virtual reality platforms or platforms for tablets or PCs.

Postoperative Care

Communicate with your surgeon to see whether virtual visits can be used to replace a day 1, week 1, or month 1 postoperative visit. Although this is not the traditional standard of care, it may be useful to limit the frequency of office visits for the sake of safety and social distancing. One caveat for these virtual visits would be to have a lower threshold for identifying patients who may need to be seen on the same day. There are no current telemedicine codes that can be billed during the global postoperative time period, but this may change.

Maximizing Use of Space

For practices with multiple providers and limited space, developing a telemedicine template (see Telehealth Triage Considerations) can be an opportunity to allow all providers to stay active while maintaining social distancing. Consider bringing patients in for testing-only days and then scheduling a telehealth visit to review the data and treat accordingly.

TELEHEALTH TRIAGE CONSIDERATIONS

ELIGIBLE CONDITIONS/SYMPTOMS

  • Burning/foreign body sensation
  • Fluctuating vision
  • Nonpainful red eyes
  • Eyelid swelling/bumps
  • Eyelid twitch
  • Foreign body sensation
  • Light sensitivity
  • Subconjunctival hemorrhage
  • Tearing
  • Conjunctivitis
  • Diplopia

NONELIGIBLE CONDITIONS/SYMPTOMS*

  • New multiple floaters and flashes
  • Sudden loss of vision
  • Temporary vision loss 1 hour to 24 hours
  • Painful eye
  • Traumatic conditions (eg, corneal abrasion, fight, accident)
  • Sudden onset headache

*Postoperative complications within the 90-day global period that should be seen in person

Attracting New Patients

Offering virtual services can be a way to attract new patients. You can promote these services on your website and in office materials, in addition to offering them to patients for follow-up exams when appropriate. In the current environment, many patients want clinically efficient health care delivery via virtual platforms. The availability of these services may also encourage patients to contact us first when they have an urgent or emergent ocular problem, rather than their primary care provider, or, possibly worse, traveling to an emergency department where the doctors may have little experience in the diagnosis and treatment of eye conditions.

GROW THE PRACTICE

No technology can replace the care that we provide our patients in our offices. From remote examination alone, we cannot acquire the magnified views of the anterior segment that we can at the slit lamp. We cannot obtain IOPs or analyze the optic nerve and retina remotely with current technologies. What’s missing even more is the physical touch, the empathic ear, the bright smiles, and the candid conversations, which can never be replaced virtually.

Nevertheless, we have a great opportunity to strengthen and grow our practices through the use of telemedicine. Our profession faces numerous threats, but virtual care provides a chance to strengthen our relationships with existing patients and to develop new ones.

  • 1. Abràmoff MD, Lavin PT, Birch M, Shah N, Folk JC. Pivotal trial of an autonomous AI-based diagnostic system for detection of diabetic retinopathy in primary care offices. NPJ Digit Med. 2018;1:39. Published 2018 Aug 28.
  • 2. Rogers TW, Jaccard N, Carbonaro F, et al. Evaluation of an AI system for the automated detection of glaucoma from stereoscopic optic disc photographs: the European Optic Disc Assessment Study. Eye (Lond). 2019;33(11):1791-1797.