June 3, 2019
By Jeffrey C. Krohn, OD, FAAO
Fig Garden Optometry, Fresno, CA
The rules have changed. “Managing an emerging pediatric myope” used to mean a patient in the daily schedule that took the least amount of time resulting in an eyeglass prescription. But now, with a myopia epidemic upon us, practitioners are called to intervene, stepping in with information and skill to “make a dent” in the refractive error universe by guiding these young eyes to avoid high myopia. But how do we fit it in, how can we create an action plan for efficient, clinically excellent orthokeratology care among the hustle and flow of a primary eye care optometric practice? While this is still a work-in-progress, I’d like to propose a blueprint.
Be Ready With Information
Without a prepared system, educating the purpose and process of orthokeratology to the parent and the child can destroy the office flow. Parents will want to know what impact this new approach will have on the family dynamic, the parent’s and child’s daily routine, and the family budget. The doctor can’t handle these “nuts and bolts.” You must delegate by having a trained staff member and educational materials ready. A short and “to the point” flyer or handout that directs patients to your online presence is extremely effective. Updates, changes, new videos, and links to other websites can all be managed more dynamically using an online repository of educational materials.
Be Efficient With the Schedule
It has been our experience that myopia management with orthokeratology is never done well if it commences at the “discovery visit” (typically an annual examination). Instead, we make a second appointment for a later day that will include training in lens wear and care. While we previously used a pre-configured trial lens set, we have been moving to a customized first pair approach. To emphasize the importance of the evaluation process, we also schedule the patient for appointments the morning after the evaluation, one week later and then one month later (i.e., the patient makes all four appointments at one time). This approach was not unfamiliar to us but is the same approach we use with refractive and cataract surgery patients.
When the patient comes in for the evaluation of orthokeratology lenses on the eye, the lenses have been pre-selected and prepared by the clinical team member. The evaluation of the lenses is typically straight forward. Almost every time the lenses have been designed and manufactured well and can be dispensed that day with instruction to wear the lenses that night and into the office the next morning.
We have created sub-categories within our scheduling template that directs the clinical team in advance to know which tests to perform for a given appointment. The “first morning” orthokeratology appointment is a “CL: response” appointment and the office team know that:
- a) patients are to wear their lenses in for this appointment, b) an over-auto-refraction is done and c) visual acuity is taken with the lenses. The doctor evaluates the lenses on the eye, removing them to assess ocular health and refractive status. Resources (people and space) for instruction in proper lens wear and care are also reserved for that visit. For all subsequent orthokeratology appointments, the testing is reversed: a) the patient is to bring, not wear, the lenses into the office, b) an uncorrected acuity is taken and c) an auto-refraction without lenses is obtained. The doctor then evaluates the ocular surface and the refractive status, completing the visit by applying the lenses and evaluating them on the eye.
Note: We have found it very useful to create special appointment slots named “Consult:1” in our template. These spots are only available to patients who are being recalled for less than a month. Appointments greater than a month out (Consult: 2 and Consult:3) go into different slots. Each doctor has 2 or 3 of these Consult:1 slots in each 4-hour patient care block. Saving these spaces has allowed us to schedule patients back for visits within a short period without having to add them to an already full schedule. Also, if these spots are unfilled for a given day less than 36 hours in advance, we offer them to new patients who call and need a comprehensive eye and vision examination.
Be Smart With Fees
Orthokeratology has no appropriate CPT code; my advice is don’t use one. While unforeseen visits related to an ocular response would be appropriately coded using CPT and ICD-10-CM, all testing, services, and products related to orthokeratology are a private matter between you and your patients. We do not bill any insurance plan for services or materials related to orthokeratology unless the plan SPECIFICALLY states that doing so is allowed. Our office prefers to package orthokeratology as a 21-month package that includes initiation of care, all lenses needed to maximize treatment and then two pair of retainer lenses. Visits occur at three-month intervals. At the 24-month mark, patients move into an annual service fee. Be prepared to handle patients who either a) drop-out or b) break or lose lenses. There is no “perfect method” to handle the unexpected. However, it is very wise to have a policy in place that is “the strictest” you would be comfortable implementing and then exercise “grace” in specific situations as you see fit.
With a commitment to the best pediatric patient care and continuous improvement, your office can fit orthokeratology into its busy schedule just as you have incorporated glaucoma care, refractive surgery, cataract care, and retinal care. Incorporating orthokeratology for myopia management into your primary care optometric practice will pay great dividends for both your office and your pediatric patients.
Jeffrey C. Krohn, OD, FAAO, Diplomate (ABO and AAO), practices at Fig Garden Optometry in Fresno, California.