WORKSHOP B Ophthalmic Imaging: All Hands on Tech! COPE Course PS

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1 WORKSHOP B Ophthalmic Imaging: All Hands on Tech! COPE Course PS

2 Ophthalmic Imaging: All Hands on Tech! Southern College of Optometry April 17, 2015 COPE #44334-PS Faculty Dr. Michael Gerstner Dr. Jason Duncan Dr. Lindsay Elkins Dr. Jennifer Sanderson Dr. Trish Walker Commercial Disclosure The content of this course was prepared independently by Drs. Gerstner, Duncan, Elkins, Sanderson, and Walker without any input from members of the ophthalmic industry. Drs. Gerstner, Duncan, Elkins, Sanderson, and Walker do not have financial interests in any companies, products, or services mentioned in this presentation. 1

3 Correspondence The Eye Center at SCO 1225 Madison Ave Memphis, TN Course Description This hands-on course will review the role of Optometry regarding the utilization of current technology for diagnosis, progression, and documentation of ocular disease and vision-related problems. Optical coherence tomography, fundus auto-fluorescence, endothelial cell spectral microscope, non-invasive ultrasonography, and other clinical technologies will be discussed and practiced in a lab setting. A Brief History of OCT Time domain (old) verses spectral domain (new) 2

4 ILM NFL GCL IPL INL OPL ONL ELM IS OS RPE Choroid It is impossible to discuss retina without knowing this slide CIRRUS HD OCT 5000 Indications, contraindications, and risk OCT set-up Patient positioning OCT image selection OCT image capture CIRRUS HD OCT 5000 Macular cube 512 x 128 Macular cube 200 x 200 HD 5 - line raster Optic disc cube 200 x 200 Anterior segment 5 - line raster Anterior segment cube 512 x 128 3

5 CIRRUS HD OCT 5000 Optic Nerve Analysis Optic nerve 200 x 200 ONH and RNFL OU analysis 3D visualization Guided progression analysis Advanced visualization Anterior Segment Analysis Anterior segment 5 line raster Anterior segment cube 512 x 128 3D visualization Anterior segment analysis CIRRUS HD OCT 5000 Macular analysis Macular thickness Ganglion cell analysis Macular change analysis Advanced RPE analysis 3-D and advanced visualization 5 line raster High definition image Billing and Coding Coding and Medicare allowable fee structure 2015 Tennessee 92134: Retina = : Fundus Photography =

6 Billing and Coding Pitfalls Vision insurance, medical insurance, or both? ICD-9 codes and baseline testing Photography and OCT Calendar year and OCT The eye is considered to be a single organ Clear documentation and interpretation A - Scan A - Scan 5

7 B Scan Ultrasound RD RD 6

8 RD/PVD Retinoblastoma Choroidal Melanoma 7

9 Choroidal Melanoma Choroidal Hemangioma Choroidal Hemangioma 8

10 Choroidal Metastasis Posterior Scleritis Posterior Scleritis 9

11 Disc Drusen Disc Drusen Disc Drusen 10

12 Posterior Staphyloma Posterior Staphyloma Choroidal Melanoma 11

13 Vitreous Hemorrhage PVD External Ocular Photography Indications: For Documentation of Medical Progress (Anterior Segment) Documents: External Structures of the Eye: lids, lashes, sclera, conjunctiva, and cornea Anterior Segment: Anterior Chamber, Iris, Crystalline Lens and filtration angle (Information from EyeCOR Coding System February 2015) 12

14 ICD-9: Requires interpretation Order, quality assessment, findings, progression, plan Bilateral Unilateral us 52 modifier for reduced services Mutually exclusive with Gonioscopy (92020) Same day must have different diagnosis and use -59 modifier Topcon SL-D7-D8Z Software: IMAGEnetLite 13

15 Capture Screen: Adnexa: Meibomian Gland Dysfunction - Lid margin telangiectasia - Gland Capping - Diffuse illumination - High Magnification 14

16 Pyogenic Granuloma: Benign Eyelid Lesion: Chronic Blepharitis -Developed over longstanding Chalazia Interstitial Keratitis: High Magnification - Diffuse illumination - Flash 2-3 Corneal Abrasion: Diffuser, Low Mag, Low Flash Cobalt, wide beam, low flash 15

17 Anterior Chamber: Uveitis (+) Cell/Flare High Mag Flash: 3-4 Posterior Synechiae No Diffuser 16x 2-3 flash Iris Neovascularization Lower Flash High Flash 16

18 Neovascularization of the Angle (+) Gonio Lens (+) 16 x Flash 2-3 Displaying Images IMAGEnet Lite is EMR compatible Can upload to Compulink ZEISS Forum Patient added to worklist Highlight individual photo or 4-Up cluster Utilities- Export Images-Pt name as file name- Save- JPEG max quality-ok Pull up forum from taskbar, photo appears (close it), highlight pt in worklist, click send, select eye Zeiss Visucam NM/FA Non mydriatic camera, capable of taking pictures through 3.3 mm pupil Useful for documenting posterior segment disease, fluorescein angiography Software options: Fundus Autofluorescence Stero photos Indocyanine Green Angiography 17

19 Zeiss Visucam with FAF FAF technique based on specific excitation and detection of natural fluorescence of retinal compounds (lipofuscin) This is achieved by use of specific spectral exciter and barrier filters Single shot-technique that works in the blue-green spectral range (~520nm) Fluorescence Fluorescence: capability of absorbing light at a specific wavelength and releasing it a longer, less energetic wavelength, use of NaFl dye Fluorescent minerals emit visible light when exposed to UV Light. Image courtesy of Zeiss Autofluorescence Autofluorescence: spontaneous fluorescence that some substances present naturally Fundus Autofluorescence: retinal photoreceptors contain light-sensing molecules (retinoids) Photoreceptors shed damaged out segments, which the retinal pigment epithelium (RPE) ingests Main autofluorescent component of RPE is lipofuscin (LF) 18

20 Lipofuscin Biomarker evident in normal aging and chronic disease Accumulates throughout life in RPE Believed to be toxic and interfere with normal cell function Evident in ocular disease before visual cycle begins to degrade Indications for FAF Technique Less invasive than FA Early identification of AMD (alteration at level of RPE visible before observed clinically) Monitoring of progression of AMD Retinal dystrophies (Best s, Stargart) Glaucoma evidence of hyperfluorescence in parapapillary region of ONH Choroidal lesions aid in identifying subtle LF, progression of tumor growth Interpretation Hypofluorescent areas: RPE atrophy/cell death Fresh hemorrhages Exudative lesions Areas of dense hyperpigmentation Some forms of hard drusen 19

21 Interpretation Hyperfluorescent signals: Yellow lesions associated with LF disease (Best s, Stargardt s) Older hemorrhages (due to fluorophore buildup in blood) Large/soft drusen Healthy Eye Pigment Changes/Drusen 20

22 Early AMD Geographic Atrophy Color photos vs FAF indicating extent of GA Retina Oct; 32(9): Geographic Atrophy Comparison of extent/appearance of a lesion with color photos, FAF and Fluorescein Angiography Image courtesy of Zeiss 21

23 Progression of GA VRMNY Best s Disease Stargardt Disease and Fundus Flavimaculatus 22

24 Optic Disc Drusen retinagallery.com Billing and Coding Fundus photo with interpretation Bilateral code $72.62 MCR allowable Specular Micropscopy Review of endothelium cell count operations Indications, risks and contraindications Interpretation Billing and Coding Konan CellChek XL Specular Microscope 23

25 Indications Patient complaints Fluctuating vision Blurry vision Foreign body sensation Photophobia Contact lens intolerance Haloes around lights Indications continued Ocular disease Glaucoma, retinal disease, recurrent iritis, keratoconus Long term contact lens wearers Systemic disease Diabetes Long term medications Surgeries Risks and Contraindications Minimal 24

26 Billing and Coding CPT special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count. Bilateral In Tennessee-$35.65 Criteria Slit lamp evidence of endothelial dystrophy (371.57) Slit lamp evidence of corneal edema ( ) Prior to secondary IOL implantation (379.31) Billing and Coding Criteria Previous intraocular surgery and require cataract surgery (V45.69) Undergo a surgical procedure associated with a higher risk to corneal endothelium (phacoemulsification or refractive surgery) Evidence of posterior polymorphous dystrophy of the cornea (371.58) or iridocornealendothelium syndrome (364.51, ) Prior to fitting with extended wear contact lenses after intraocular surgery (379.31, V43.1, V45.69) Billing and Coding Chart should contain the following: An order for the test with medical rationale The date of the test The reliability of the test The test findings A diagnosis The impact on treatment and prognosis Signature of the physician 25

27 Billing and Coding Frequency Medically indicated for new symptoms, disease progression, new findings, unreliable prior results, or a change in treatment plan. Clear documentation for the reason required Interpretation CD-Cell Count or Endothelial Cell Density DV-Coefficient of Variation HEX-Hexagon cells NUM-The actual number of cells use to calculate the results Pachy-Pachymetry SD-Standard Deviation 26

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