Cataract and Refractive Surgery Co-Management Policy and Procedure Manual Michael R. George, M.D. Chief Surgeon and Medical Director Tylock-George Eye Care
Index of Cataract and Refractive Surgery Manual Cataract Surgery Protocol Refractive Surgery Protocol Interoffice Communication Form Cataract Surgery Patient Forms Refractive Surgery Patient Forms
About Us General Contact Information Mailing Address: Tylock-George Eye Care Telephone: (972) 258-6400 Fax: (972) 570-1103 Website: www.tylock.com Surgical Co-Management Coordinator Contact Information: Kyle McKinnon (Refractive/LASIK Co-Management & Other) William Chavez (Refractive/LASIK Co-Management) Jason Watson (Cataract Surgery Co-Management)
Meet our Doctors Physicians and Specialties: Dr. George, a board certified Ophthalmologist, was honored to join Tylock Eye Care and Laser Center in 2012. Since becoming Director and Chief Surgeon he has strived to provide his patients with the highest quality of vision possible. Dr. George and Dr. Tylock were the first surgeons in Texas to use the advanced WaveLight Refractive Suite Laser. Using cutting edge LASIK techniques he has helped thousands of patients to enjoy life beyond glasses and contact lenses. Dr. Michael R. George, M.D. Dr. George is also a specialist in cataract and lens implant surgery. This surgery is used to implant the Crystalens, ReSTOR, and Tecnis Multifocal intraocular lenses, allowing patients in their late 40 s and older to see at far as well as near. Dr. O Keefe is a Doctor of Optometry focused on patient exams, often in an emergency setting, with an emphasis on glaucoma, macular degeneration, diabetic retinopathy, and vascular occlusive disease. Dr. O Keefe is now a member of the long standing and respected Tylock- George Eye Care Center. She provides comprehensive optometric care, including glasses prescription, LASIK Consultation, Intraocular Cataract Surgery Consultation, post-operative care, and diagnosis and treatment of general eye conditions. Dr. Alanna O Keefe, O.D. Dr. Sanchez is a Doctor of Optometry and Optometric Glaucoma Specialist focusing her practice on comprehensive eye examinations for the diagnosis and treatment of ocular disease. She is an active member of both the American Optometric Association and Texas Optometric Association. She is proficient with state of the art diagnostic equipment and treatment techniques to assess candidacy for cataract and refractive surgeries, and she is trained to perform pre and postoperative care. Dr. Rosmary Sanchez, O.D., M.B.A.
Welcome We would like to personally thank you for entering into co-management with Tylock-George Eye Care. Our doctors, ophthalmic technicians, surgical coordinators and receptionists operate as a team. We take pride in our staff's knowledge and capabilities, and we want you to have the same confidence in them. In this packet, you will find inter-office communication forms and our office guidelines for patient referrals. We hope this will make it easier to have seamless communication between our offices. Tylock-George Eye Care is an all-inclusive ophthalmic practice founded in 1984 by Dr. Gary R. Tylock. We specialize in Refractive Cataract Surgery, LASIK, PRK, ICL, and comprehensive eye care. We offer the most advanced methods for vision correction in the North Texas DFW surrounding area. Our physicians are specialists in the most comprehensive eye conditions with a commitment to personalized care resulting in a long-standing reputation for excellent treatment and care. We combine full service patient care with experience, expertise, and excellence providing a wide variety of eye care services. Our staff is dedicated to assisting patients with achieving their visual goals. We look forward to working alongside you to provide our mutual patients with the best care available. Sincerely, The Doctors at Tylock-George Eye Care Michael R. George, M.D. Gary R. Tylock, M.D. Rosmary Sanchez, O.D. Alanna O Keefe, O.D.
Co-Management Referral Protocol 1. Consult Request Please fill out a Consultation Request form and fax along with the patient s demographic and insurance information to Jason Watson (Cataract) or Kyle McKinnon/William Chavez (Refractive) attention to fax # 972-570-1103. You may call our office directly and ask for Kyle McKinnon or William Chavez at 972-258-6400 to schedule an appointment directly at Tylock-George Eye Care. Upon completion of the evaluation with the surgeon, the surgical coordinator will fax you an evaluation report with plan scheduled procedure dates. 2. Post Operative Exam The surgeon will perform the same day post-operative exam. The patient will be released to your care upon stable post-operative exam, with written therapy instructions. If the patient desires surgery on their second eye, the surgeon will perform the 1 week postoperative exam. If the patient does not desire a second surgery, patient will return to your office for their future care. i. An evaluation form will be faxed to you. ii. Please return your post-operative care results to our office by fax. If your office is not in network with the patients medical insurance, or if the patient is on Medicaid or Medicare HMO we will perform their post-operative care and they will return to you for their glasses. If any complications should arise, please do not hesitate to refer the patient back to the surgeon. 3. Billing and Coding When billing for co-management reimbursement, a modifier 54 will be used for the surgeon's claim and modifier 55 will be used for the referring doctor's claim. Each office will submit claims independently. We are in network with the majority of major medical and many other insurance policies. Please call our office if you have any questions or concerns. Refractive procedures are elective and not covered by the majority of insurance plans. If you need help submitting claims, or enrolling in Medicare please feel free to reach out to us. We are here to help in any way we can.
Please Keep Us Up-to-Date It is imperative that all of our communication findings match the patients' chart, in order to provide optimal patient care. Once the following is received, we will finish the processing: Co-management consent form 1 week post-operative exam 4 week post-operative exam Cataract Surgery Protocol The optometrist may refer to the ophthalmic surgeon when he/she feels it is clinically appropriate and in the patient's best interest. The ophthalmic surgeon and optometrist will know and comply with coding and billing requirements of Medicare and other payers. Good Candidates for Cataract Surgery Best visual acuity is 20/50 or worse Best visual acuity 20/40 with a significant loss of acuity in bright light conditions (Glare or BAT testing) Significant anisometropia Vision impairing ability to carry out activities of daily living Need to visualize the fundus (Retina) or optic nerve for ocular health and monitoring
Good Candidates for a Multifocal IOL o 1.5 diopters of cylinder or less o Healthy ocular surface and macula o Desire to be independent from glasses most of the time Contraindications: o Any significant ocular surface disease o Any macular pathology Good Candidates for a Toric IOL o 0.75 diopters of cylinder or greater o Desire to be independent of glasses at a distance most of the time o Preoperative Regular Astigmatism
Preoperative and Post-Operative Roles Of the Ophthalmic Surgeon and Optometrist Ophthalmic Surgeons Pre-Operative Role Perform and document an independent evaluation of patient's eligibility, including slit lamp examination Assess the patient's clinical status Assess the physiological, social, emotional, and occupational needs of the patient Educate patients of the different options in cataract surgery Recommend the lens/procedure type he/she feels will benefit the patient Inform patient of the additional cost of Multifocal, Toric, and/or use of femtosecond laser as private insurance companies and Medicare will not cover these costs Document in medical record that the risks, benefits, and alternatives were discussed Obtain informed consent Offer patient copy of procedure specific consent form Obtain patient's consent for planned co-management Ophthalmic Surgeons Pre-Operative Role We will schedule one eye at a time per Medicare and insurance guidelines. Sufficient time will be given between each surgery to diagnose and treat the medical and refractive stability of the first eye. If the patient elects to have surgery on their second eye, it will be determined by the surgeon no sooner than their 1 week postoperative appointment. The ophthalmic surgeon must perform and document an independent evaluation of patient's eligibility, including a slit lamp examination of the second eye.
Post-Operative Care Following Cataract Surgery This is a guideline and will be left to the co-managing optometrist's discretion Post-Operative Exams Following Day or One Day Post-Op (Performed by Surgeon) Perform the post-procedure discharge evaluation and provide written postoperative care instructions Determine when the patient is stable and can be referred to co-managing optometrist as planned Remain available throughout the postoperative period at request of patient or co-managing optometrist Recommended Timeline for Post-Operative Evaluations 1 week 4 week 3 month, then 1 year (1 year for ATIOL only) All Post-Operative Exams to Include Interval history taking Auto or Manual Refraction (If Needed) Visual Acuity Testing (at both distance and near for multifocal intraocular lens) Intraocular Pressure Check Slit-lamp Examination Management Plan (continuing medications, restrictions, further post-operative appointments) It is imperative that co-managing optometrists send co-management forms/exams to our office after each examination, as it is required for surgeon to review, date, and sign each exam/test/report. We will send you all exams and forms performed by our ophthalmic surgeon.
If the patient is deemed stable by the ophthalmic surgeon, they will be referred back to their co-managing optometrist after the one day post-op exam. (If two eyes are to have surgery the patient will be sent back after the second one day post op exam.) Some potential common complications from cataract surgery which should be monitored for are Corneal Edema, Macular Edema, and increased Intraocular pressure. Co-Managing optometrists should consult or refer back to the ophthalmic surgeon for the following conditions: Intraocular pressure greater than 25, Macular Edema, Recurrent Erosion, Retained Cortex, Retinal Detachment, any sign of abnormal inflammation, any sign of infection, or prolonged Corneal Edema (greater than 1 week). Our surgeons are available throughout the post-operative period to consult with the co-managing optometrist or patient for any questions or concerns and are encouraged to do so. If transferring care back to the ophthalmic surgeon, the optometrist will inform the patient of the need to refer to the surgeon and will document and/or communicate his/her exam findings to the ophthalmic surgeon. The patient has the right to receive treatment from the ophthalmic surgeon at all stages of care, the ophthalmic surgeon will be notified by the optometrist when a patient requests to see him. At all times the ophthalmic surgeon will be available via phone for consultation. The patient will be given the after-hours answering service phone number at the one day post-operative exam to be used after hours. Please do not hesitate to contact our office/surgeons at any point during the care of shared patients.
Refractive Surgery Protocol The optometrist may refer to ophthalmic surgeon when he/she feels it is clinically appropriate and in the patient's best interest. The ophthalmic surgeon and optometrist will know and comply with coding and billing requirements. Good Candidates for Refractive Surgery LASIK/PRK Over the age of 18 Sufficient corneal thickness Spherical equivalent of + 6.00 to - 12.00 5.00 Diopters of cylinder or less Stable refraction Visian STARR ICL (Implantable Collamer Lens) Ages 18-50 Anterior chamber depth 3mm or greater Spherical equivalent -3.00 to -20.00 1.50 diopters of cylinder or less Stable refraction Clear Lens Exchange Over the age of 40 Any spherical equivalent 1.50 diopters of cylinder or less for Multifocal IOL 5.00 diopters of cylinder or less for Toric IOL Stable refraction Contraindications: Pre-existing eye conditions (i.e. Glaucoma, Iritis, Fuch s dystrophy, Amblyopia, Diabetic Retinopathy, Keratoconus), autoimmune diseases, Herpes simplex or Herpes zoster near orbit, pregnant or breastfeeding women.
Refractive Pre-Operative Roles of the Ophthalmic Surgeon and Optometrist Patients who are interested in refractive surgery will have a consultation with our refractive coordinator (either in-office or over the phone) prior to being scheduled for an evaluation with Dr. George. Patients will be asked to discontinue their contact lens wear during this evaluation process in order to obtain stable/accurate measurements. Ophthalmic Surgeons Pre-Operative Role* Perform and document an independent evaluation of patient's eligibility, including slit lamp examination Assess the patient's clinical status Assess the physiological, social, emotional, and occupational needs of the patient Educate patients of the different options in cataract surgery Recommend the procedure he feels will benefit the patient Document in medical record that the risks, benefits, and alternatives were discussed Obtain informed consent Offer patient copy of procedure specific consent form Obtain patient's consent for planned co-management Perform laser iridotomies on ICL patients
Post-Operative Guidelines and Protocols for Refractive Patients This is a guideline but will be left to the co-managing optometrist s discretion LASIK Day 1 post op (with surgeon) Prednisolone Acetate TID x 2 weeks Or Durezol BID for 6 days ICL Day 1 post op (with surgeon) Prednisolone Acetate TID x 2 weeks PRK Day 1 post op (with surgeon) Day 4 or 5 post op (with surgeon) Prednisolone Acetate (or FML) TID x 2 weeks then BID x 4 weeks CLE Day 1 post op (with surgeon) Prednisolone Acetate BID x 2 weeks Post-Operative Exam Schedule One Day Post-Op (Performed by Surgeon) Perform the post-procedure discharge evaluation and provide written postoperative care instructions Determine when the patient is stable and can be referred to comanaging optometrist as planned Remain available throughout the postoperative period at request of patient or co-managing optometrist If the patient is deemed stable by ophthalmic surgeon, patients will either be referred back to co-managing optometrist after the same day post-op or after removing bandage contact lens at day 4-5 for PRK patients. Recommended Timeline for Refractive Patients Post-Operative Evaluations 1 week 1 month 3 month 1 year
Post Operative Exams to Include Interval history taking Auto or Manual Refraction (If Needed) Visual Acuity Testing (at both distance and near for multifocal intraocular lens) Intraocular Pressure Check Slit-lamp Examination Management Plan (continuing medications, restrictions, further post-operative appointments) It is imperative that co-managing optometrists send co-management exams to our office after each examination, as it is required for surgeon to review, date, and sign each exam/test/report. We will send you all exams and forms performed by our ophthalmic surgeon. Some potential common complications of surgery which should be monitored for corneal edema, chronic dry eyes, and night vision problems. Co-managing optometrists should consult or refer back to the ophthalmologist for following conditions: Intraocular pressure greater than 25, Recurrent Erosion, Prolonged Corneal Edema, Macular Edema, Retinal Detachment, Epithelial Ingrowth, Corneal haze, Abnormal inflammation, Sign of infection, Corneal infiltrates, or Regression. Our surgeons are available throughout the postoperative period to consult with the co-managing optometrist or patient for any questions or concerns and are encouraged to do so. If transferring care back to ophthalmic surgeon, the optometrist will inform patient of the need to refer to the surgeon and will document/communicate his/her findings to ophthalmic surgeon. The patient has the right to receive treatment from the ophthalmic surgeon at all stages of care. The ophthalmic surgeon will be notified by optometrist when a patient requests to see him. At all times the ophthalmic surgeon will be available via phone for consultation. The patient will be given the after-hours call center phone number at the one day postoperative exam to be used after hours. Please do not hesitate to contact our office/surgeon at any point during the care of our shared patient.
Interoffice Communications Forms All forms are available at www.tylock.com within the Physician Portal link at the top of the website home-page. If you have any trouble accessing this link please contact one of our counselors or management team and we will email or fax your office any needed forms. The Physician s Portal Is Located at the Following Website Address: http://www.tylock.com/portal/ Forms Include: Consultation Request, Consent for Co-Management, Evaluation Reports, Post-Operative Co-Management Exam