Continuing Education in Austince.opt.uh.edu/lg-files/Sunday.Print.Version.Course.Notes.pdf · 11:05...

Course Notes September 24-25, 2016

Omni Austin Hotel Downtown 700 San Jacinto at 8th St, Austin, TX 78701

Austin Continuing Education in

presents:

SATURDAY, SEPTEMBER 24 7:00 am to 8:00 am Registration, Continental Breakfast & Visit Exhibits 8:00 am to 8:05 am Announcements & Introductions

Lectures presented by Walt Whitley, OD, MBA, FAAO:

8:05 am to 9:45 am Evidence Based Medicine: Perspectives and Impact of Clinical Research on Patient Care

COPE ID # 47727-SD 2 D/T Hours

9:45 am to 10:15 Break & Visit Exhibits 10:15 am to 11:05 Cosmetometry: A New Wrinkle for Optometry COPE ID # 45368-AS 1 D/T Hour

11:05 am to 12:00 Trauma for the OD: A Case Management Approach COPE ID # 46105-AS 1 D/T Hour

12:00 pm to 1:00 Lunch & Visit Exhibits

Lectures presented by Ashley Wallace Tucker, OD, FAAO:

1:00 pm to 2:40 pm How to Fit and Troubleshoot Scleral Contact Lenses COPE ID # 50202-CL CEE Available 2 GEN Hours

2:40 pm to 3:10 pm Break & Visit Exhibits 3:10 pm to 3:15 pm Raffle Drawing 3:15 pm to 4:05 pm New Advancements in the Management of

Keratoconus COPE ID # 50194-AS

1 D/T Hour

4:05 pm to 5:00 pm Clinical Management on the Effects of Blue Light COPE ID # 50196-PS 1 D/T Hour

SUNDAY, SEPTEMBER 25 7:00 am to 8:00 am Registration, Continental Breakfast & Visit Exhibits 8:00 am to 8:05 am Announcements & Introductions

Lectures presented by Bruce Onofrey, OD, RPh, FAAO:

8:05 am to 9:45 am Management of Ocular Infection: The Next Generation

COPE ID # 50114-AS CEE Available

2 D/T Hours

9:45 am to 10:15 am Break & Visit Exhibits

10:15 am to 12:00 pm Management of Ocular Pain and Inflammation COPE ID # 48570-PH CEE Available

2 D/T Hours

12:00 pm to 1:00 pm Lunch & Visit Exhibits Lectures presented by Joe DeLoach, OD, FAAO:

1:00 pm to 2:40 pm Billing and Coding – Just the Facts, Mam… COPE ID # 50113-PM CEE Available

2 GEN Hours

2:40 pm to 3:10 pm Break & Visit Exhibits 3:10 pm to 3:15 pm Raffle Drawing 3:15 am to 4:05 pm Anterior Segment Misadventures COPE ID # 43863-AS 1 D/T Hour

4:05 pm to 5:00 pm 2016 Professional Responsibility Course COPE ID # 48222-EJ 1 GEN Hour

CE in Austin September 24 -25, 2016

COPE Event ID# 111742

CourseMaster Pat Segu, OD, FAAO

Location Omni Austin Hotel at Downtown

700 San Jacinto @ 8th Street Austin, Texas 78701

Management of Ocular Infection: The Next

Generation

Bruce E. Onofrey, OD, RPh, FAAO

Professor, U. Houston

UEI

Entero-from the gut

EHC-Epidemic Hemorrhagic Conjunctivitis

Called Apollo 11 disease after outbreak in Africa from 1969-70

Enterovirus type 70

Minimal corneal signs

Big PA nodes common

Enteroviruses: The “REAL “PINKEYE”

KWIK CASE 2:Take a guess

S: 17 Y/O Female with c/o itching , watering red OD X 24 hours associated with flu-like symptoms.

O: “Mixed” conjunctivitis

NO Pre-Auricular

node

Mucous like discharge with

erythema OD

Pseudomembrane OD

Cornea: Multiple infiltrates

Unilateral presentation

Viral conjunctivitis is the #1 Cause of ACUTE

INFECTIOUS Conjunctivitis (in adults)Adenovirus

Enterovirus

Adenoviral Signs@@@@

Follicular conjunctivitis-Variable most common in lower fornix

Mild to moderate chemosis

Lid swelling with mild ptosis

“Watery” discharge

Lymphadenopathy in 66%

REMEMBER

ADENOVIRAL DISEASE IS BILATERAL

****EVENTUALLY******

CLASSIC PRESENTATIONS

ARE ONLY FOUND IN TEXTBOOKS

DNA Viruses

At least 35 different serotypes

Type 8 Classic EKC

Types 10, 13, 19, and 37 NEW EKC

NEW VIRUS = INFLAMMATION

Adenovirus Family

DOES SELF-LIMITING DISEASE NEED TREATMENT?

SELF-LIMITING DOES NOT MEAN HARMLESS

INFECTIVE PROCESS IS THE SELF LIMITED FACTOR

INFLAMMATION IS NOT

TREAT TO PREVENT INFLAMMATORY DAMAGE

Cool compresses and ASA

Lubrication

Decongestants

Steroids (infiltrates, membranes,

inflammation)@@@@

Membrane removal

Antibiotics??

TREATMENT OF BOTH SYMPTOMS AND PREVENTION OF INFLAMMATORY DAMAGE

Is there a Cure for the Common Cold of the eye?

NOT QUITE• Spit and swish: Povidone 5%

ophthalmic solution

• Don’t spare the steroids

THE CURE?

Decrease infection from 18 to 7 days

Fewer complications

Tabbara K, Jarade E. Ganciclovir effects in adenoviral keratoconjunctivitis. Invest Ophthalmol Vis Sci.

Currently in Animal Testing

FORESIGHT PHARMACEUTICALS

Topical FST100 Dexamethasone 0.1% Containing Povidone-Iodine 0.4% Reduced the Clinical Signs and Infectious Viral Titers in a Rabbit Model of Adenoviral Conjunctivitis

KWIK CASE #3LIKE FATHER, LIKE SON

3 Week old newborn with sudden onset mucopurulent mixed conjunctivitis

Father with unilateral “GIANT” follicular conjunctivitis

Marked pre-auricular nodes in both patients

CHLAMYDIA FACTOIDS

#1 CAUSE OF CHRONIC CONJ. AND OPHTHAMIA NEONATORUM

STD

Mother should be checked prior to birth

Onset in 2nd week post-partum

Potential conjunctival scarring

Systemic complications

ChalmydiaTreatment

Both topical and systemic

Treat parents and friends also

The family that gets treated together stays together

Erythromycin ophth. Oint

Zithromax 10mg/kg/day X 1 day, then 5mg/kg/D X 4 days

Adults: 1 gm SINGLE DOSE

KWIK CASE 3A 24 Y/O SCL patient

Crusty lid lesion OD

Red painful eye OD X 48 hours-”getting worse”

“Mixed” conjunctivitis

No CL X 24 hours

3rd time this year “pink eye”

(+PA node on R side)

Looks a lot like this case-3B

Sent in as H. simplex blepharitis-

IT WASN’T

Disinfectants and infection

• Broad anti-infective efficacy

• Ionic

• Some stain

• Uncomfortable

• Toxic

• Not all eye approved

• Skin infections

• Pre-op

Herpes Family of Viruses@@@@

Herpes simplex

Herpes zoster

Epstein Barr-Infectious mononucleosis

CMV-Cytomegalovirus

Herpes Simplex

Type I Above waist-Trigeminal ganglia

Type II below waist-most severe in eye infection-Saccral ganglia@@@@

50% reoccurrence within 2 years

Multiple triggers@@@@

90% carry antibodies by age 10

HERPES SIMPLEX IS A UNILATERAL

DISEASE@@@@@

Characteristics of Herpes Viruses@@@

Latency

Recurrent

Herpes Simplex

Primary disease

Recurrent disease

Conjunctivitis

Keratitis

Stromal disease

Kerato-uveitis

Primary H. simplex@@@@

Pre-auricular node common

Vesicles

Follicles

No dendrite

Self-limiting disease-BUT-Treat aggressively to prevent recurrence

Stromal H. simplex-A whole new ball game

Mechanism is primarily inflammation@@@@

Stromal infiltrates are the critical sign

Balanced use of topical steroid (FML) with anti-viral cover@@@@

Consider oral acyclovir at this point in time (HEDS II)

YES, IT CAN GET EVEN WORSE

H. Simplex kerato-uveitis

Marked inflammation

Elevated IOP

Complex case

Topical vs SystemicSteroid vs no steroid

TX Mechanisms-not a Name

Know Your HEDS 1 and 2

#1: Topical for Everyone

Trifluorothymidine: THE OLD

THE FORMER drug of choice for topical management of Herpes simplex ocular disease.@@@@@

Rapid absorption

Toxicity occurs when used over 21 days

Dosage-5-8X daily

Viroptic 1%-7.5cc-Burroughs

ZIRGAN: THE NEW

Selective Toxicity

Gel formulation

Adenoviral effective?

5X/D till re-epith, then TID X 3D

The Herpetic Eye Disease Study 1 and 2 (HEDS I and II) and it’s impact on the current TX of H. Simplex Eye Disease

HX of HEDS I and II

Multicenter study of H. Simplex

1992-1996

5 separate study groups to evaluate benefits of H. simplex TX modalities and prevention benefits of oral antiviral therapies

HEDS 1 TX studies (active disease)

HEDS II Prevention studies (prophylaxis)

The KWIK HEDS 1 RESULTS

1. STEROIDS FOR STROMAL HERPES - YES

2. ORAL ANTI-VIRALS for STROMAL HERPES – DOES NOT HASTEN RESOLUTION

3. ORAL ANTIVIRALS FOR IRIDOCYCLITIS- SMALL TEST GROUP, BUT STATISTICAL BENEFIT

The KWIK HEDS 2 RESULTS

1. Oral anti-virals DO NOT prevent conversion from epithelial to stromal Herpes

2. Prophylactic use of ORAL anti-virals DO prevent REOCURRENCE of ALL forms of H. simplex

USE OF ORAL ANTI-VIRALS IN HERPETIC DISEASE

EPITHELIAL HERPES

Combine with topical to maximize therapy

Acyclovir 400mg 5X daily

Valacyclovir 500mg TID

Famcyclovir 250mg TID


DISCIFORM HERPESTOPICAL STEROID WITH ORAL ANTIVIRAL

Acyclovir 400mg 2-5X daily

Famcyclovir 125mg BID

SLOWWWW TAPER

CONTINUE PROPHYLACTIC ORALS LONG TERM (YEARS)


DISCIFORM HERPES W/KERATO-UVEITISTOPICAL STEROID WITH ORAL ANTIVIRAL




ORAL acetazolamide


HERPES ZOSTER OPHTHALMICUSTOPICAL STEROID WITH ORAL ANTIVIRAL




Glc drops as needed

NOW FOR SOMETHING TOTALLY SIMILAR

Asbell rabbit study

• Oral valacyclovir reduces risk of recurrent H. simplex after eximer PRK

• Response is highly dose dependant

• 150mg/kg X 14 days 0% reactivation

• Debridmenent did not reactivate virus

• Eximer produced reactivation

• Pre-TX?? Better results??

AND SOMETHING SOMEWHAT DIFFERENTScoper study

• 42 Dry eye patients with H. Simplex stromal keratitis

• Thermal punctalplasty

• Topical cyclosporin A

• 3 groups:

• Punctalplasy

• Cyclosporin A

• Both

Results• Non-treated group: 6-7 months of disease/yr

• TX with EITHER thermal cautery or topical cyclosporin: 1.1 months/yr of active disease

• TX with both: 0.8 months/yr

• Learning point:

• OSD patients with H. simplex require aggressive management

• Topical cyclosporin A is safe and effective in H. simplex patients

Respond To This Statement

The current standard of care is to culture ALL suspected bacterial corneal ulcers

A. TRUE

B. FALSE

What is The Standard of Care?

It’s whatever the expert witness say’s it is!!

To test or not to test?Which Tests?

ARE ALL ULCERS TREATED THE SAME?

Differential DX of InfectionThe Tests

Cultures

Diff-Quick

Gram Stain

Gram Stain (FAST)Differentiates bacteria by differences

in cell wall morphology@@@@

Designates bacteria as Gram (+) or (-)@@@@

Bacterial Ulcer Guidelines

Always culture if you have the means

Patients that get better never sue-those that don’t-DO

Consider the 1-2-3-4 rule

Fluoroquinolone mono-therapy is not fool-proof

Grade the ulcer-Location, location, etc

Step TX based on cultures

Evolution of the Quinolones

NalidixicAcid

NorfloxacinLomefloxacinCiprofloxacinOfloxacin

SparfloxacinGrepafloxacinLevofloxacin

GatifloxacinMoxifloxacin

Limited spectrumof activity

Extended spectrumEnhanced activity against

Gram-negatives

Extended spectrumEnhanced activity against

Gram-positives, streptococci,anaerobes, atypicalmycobacteria

Improved pharmacokineticproperties

H3

C N

C2H5

N

O

COOH

HNN

F

N

O

COOH

NH3C-N

F

CH3

N

O

COOH

O

N

H

OCH3

F

N

O

COOH

HN N

H

H

American Pharmaceutical Association; 2000.

Fourth-Generation Fluoroquinolone Chemical Structures

HN

OCH3

F

N

O

COOH

N

H

H

MoxifloxacinGatifloxacin

HNOCH3

F

N

O

COOH

NH3C

•1.5 H2O

Potency of Fluoroquinolones: MICs of 18 Fluoroquinolone-Resistant Endophthalmitis Isolates*

Mather R, et al. Am J Ophthalmol. 2002;133:463-466.

Med

ian

MIC

(µg

/mL

)

Coag-negStaphylococcus

S aureus

The Latest

Besivance: NEW Molecule

Moxeza: Longer duration

Zymaxid: Higher concentration

TWO MOXY’s-What’s the difference

Vigamox Active ingredient:

0.5% Moxafloxacin

Indication

Bacterial conjunctivitis

Bottle size

5cc

Dose

TID

Generic

YES

Moxeza

DITTO

DITTO

3cc

BID

NO

“TRUST ME” For MRSA-Forget the Fluoroquinolones

Back to the OLD Drugs

Trimethoprim (not just for kids)

Tobramycin

Vancomycin

Bacterial Keratitis TXEvolution of TX

Cephalexin 50mg/cc + Tobramycin13.5mg/cc: OLD DAYS

Fluoroquinolone: 2nd gen: Old days

Fluoroquinolone (2nd) + Aminoglycoside: Now 4th gen

Vancomycin 10-25mg/cc for MRSA

According to the ASCRS study, post-op refractive surgery ulcers

are a different kind of animal

% OF TOTAL PROCEDURES PRK 20% LASIK c KERATOME 50% LASIK/FEMPTOSEC. 28%

2.5 X > c PRK VS KERATOME 6 X > c PRK VS FEMPTOSEC 2.4 X > KERATOME VS FEMPTO

PRK BADDDD FEMPTO GOOOOOD

2001: Mycobacteria 48% 2004 GR (+) Staph/Strep

sp 2008 MRSA 28% 2008

EARLY INFECTIONS (2 WEEKS POST-OP STAPH (MRSA AND NON-

MRSA} STREP

LATE INFECTIONS ( > 2 WEEKS) MYCO (NON-TB) NOCARDIA FUNGAL (NOTE, 9-19%!!)

PRK AND STEROIDS!!

EARLY1. Irrigate flap with

vancomycin50mg/cc

2. 4th gen FQ Q 5MIN X 3 DOSES, THEN Q 30MIN ATC

3. ALT WITH VANCOMYCIN 50MG/CC Q 30MIN ATC

4. DOXY 100MG BID PO

LATE1. IRRIGATE FLAP WITH

AMIKACIN 50MG/CC OR CLARITHROMYCIN 10MG/CC OR AZITHROMYCIN 2MG/CC

2. 4TH GEN FQ Q 5MIN X 3, THEN Q 30MIN ATC

3. ALT WITH AMIKACIN 50MG/CC ATC

4. DOXY 100MG BID PO5. MYCOPLASMA-4TH GEN FQ6. R/O FUNGUS AND

AMEOBIC

KIDS INFECTIONS

Let’s talk Kids: Pediatric conjunctivitis plays by different rules

Don’t treat pediatric conjunctivitis without first:

Check history

Check ears

Check throat

Check temperature

Kids Conjunctivitis-NO drops alone if…..

Recurrent or active otitis media

Fever

Sore throat

Generally ill

Treat with Polytrim/fluoroquinolone and effective oral anti H. Flu

The STYE that Wasn’t

When topicals are NOT ENOUGH!

• 32 yowm swollen upper lid

• Very painful

• Warm to touch

• + HX frequent “Styes”

This lesion is best classified as a (an):

1. Stye

2. Dacryocystitis

3. Internal hordeola

4. External Hordeola

5. None of the above

DON’T Forget Your Differential DX-The Bad Signs

• Decreased Acuity

• Proptosis

• Diplopia-Extraocular paralysis

• Febrile

• Elevated WBC’s

• Get blood cultures

• Consider orbital CT scan

Orbital Cellulitis is a Life/Sight-Threatening Condition

• Patient must be hospitalized

• Parenteral IV therapy is mandatory

• Drug based on culture/sensitivitiy reports

• HX of trauma or insect bite is common

THE END

• MANY MANY THANKS!

• QUESTIONS?

9/19/2016

1

Management of Ocular Pain and

InflammationBruce Onofrey, OD, RPh, FAAO

Professor, U. Houston

1

A CLINICAL MOMENT:

80 y/o with severe temporalheadache presents to ER

ER DX:MigraineTX with Midrin

Classical Migraine Symptoms?What IS the Differential?

NOT the Rear-end of An Automobile

• Do the facts support theDX?

• What is the DifferentialDX?

• Will this TX produce harm?

• Any additional tests?

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2

The Differential

• Cranial Arteritis

• Arteritic Ischemic OpticNeuropathy

• Temporal Arteritis

• Carotid Artery Disease

• Hypertensive Crisis

• Impending CVA

The Tests

• BP

• ESR

• CRP

• CBC

• ESR >47

• CRP > 2.45

Pain is NOT a disease-It is a sign of a disorder that must be diagnosed in conjunction with

the management of the pain.

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What is Pain?

• Any unpleasant sensory and emotional experience associated with actual or potential tissue damage.

• 75 million suffer from chronic pain

• 1/3- 1/2 require daily pain management

8

Pain Management

• Acute — injury,inflammation (mostocular pain)

• Chronic

• Neuropathic — fromdiseases of the nervesor from injury to nerves

• Cancer — pain related to malignant disease or tumors and their effects on the body

9

Acute Pain

• ~ specific and obvious cause (e.g.trauma, surgery)-ALWAYS FIND CAUSE

• ~ limited duration

• Resolves when the source of pain is detected and treated

• ~ requires topical/local treatment– Fewer side effects/complications

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10

Physiologic Effects of Pain

• Tachycardia

• Systemic hypertension

• Tachypnea

• Can exacerbate pre-existing cardiovascular disease

11

Psychological Effects of Pain

• Poor sleep patterns

• Anxiety

• Uncooperativeness

12

Need for Pain

• Short latency - warn the organism thatit is in danger so it will alter thesituation (e.g.,withdraw limb, takeflight, respond with defensivemaneuver).

• Long latency - immobilize the organismso that recovery from injury can occur.

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13

Pain Mediators

• Tissue injury causes release ofchemicals

• They sensitize or activatereceptors

• Neurons release substance P,which stimulates mast cells andblood vessels

• Histamine released from mast cellsand bradykinin released fromblood vessels add to pain stimulus

Why??Why do I Have Pain?

• Pain mechanisms are complex

• Peripheral VS Central Pain

• Direct nerve stimulation-Drop hammer on toe

• Inflammatory pain-Prostaglandins

• Tissue damage-Via infection or trauma

Indications• Abrasions

• Lacerations

• Thermal and

Chemical injury

• Dacryocystitis• Bacterial

corneal ulcers

• Cryo therapy

• Micropuncture

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6

Watch Out for those Air Bags

• Blunt trauma to cornea produces a concussive trauma

• Abrasive surface can denude the epitheliumcompletely

• Temporary to permanent stromal edemaand hazing-de-compensation due to endothelial shock

• Often an associated uveitis/hyphema andother forms of blunt ocular traumatic injuries

Pain ManagementThe Drugs

• Peripheral agents: NSAID’s

• Acetaminophen?

• Central Agents: Opiates

• DMARD’s: Disease Modifying Anti-Rheumatic Drugs

17

18

Peripherally Acting Agents

• Prevent sensitizationand discharge of thenociceptors

• NSAIDs (includingASA)– Block the formation of

inflammatory and pain mediatory (e.g. prostaglandins) at the cyclooxygenase pathway

9/19/2016

7

• COX:

• COX-1: constitutive enzyme: is involved in tissue homeostasis.

• COX-2: inducible enzyme: is responsible for the production of the prostanoid mediators of inflammation.

Classification

Non-selective COX inhibitor

Selective COX inhibitor

Salicylates

Acetaminophen

Indomethacin

et al

selection

chemcialconstitution

NSAID’s: THECYCLOOXYGENASE BLOCKERS

Salicylates

• Block cyclooxygenase

• Analgesic vs Antiinflammatory dose

• Acetylated vs non-acetylated

9/19/2016

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Acetylated VS Non-acteylatedSalicylates-The FIRST NSAID’s

Non-acetylated developed to

reduce:

• GI bleeding

• GI Upset

Acetylated: ASA: Aspirin

• Irreversible block of platelets

• Best for use as an anti-coagulant

• None are safe in potential bleeders

THE SECOND GENERATIONNSAID’s

• Less bleeding potential

• Less GI Upset

• Greater efficacy

• Greater potency

• All second generation drugs have the same efficacy in EQUIVALENT DOSAGES AND THE SAME SIDE-EFFECTS

EQUIVALENT DOSAGES

• 3200mg of ibuprofen =

• 20mg of Feldene =

(800mg QID)

(20mg/D)

• 750mg of Naprosyn per day (375mg BID)

• Only differ in 1/2 life = Dosing frequency

• Only differ in dosage = Potency

9/19/2016

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NSAID SIDE-EFFECTS

• Inhibit platelets: Only ASA is irreversible

• Allergic to one, allergic to all

• Avoid in asthmatics and those with nasalpolyps-Increased incidence of allergy

• Watch out for protein binding in Type IIdiabetics@@@@

• Renal insufficiency: ALL DIABETICS AT RISK

• CHF

NSAID SIDE-EFFECTS

• Kids with fever: Avoid ASA

• Avoid pregnant or nursing mothers

• Those with GI problems

New NSAIDS• New COX-2 inhibitors for acute pain

• Vioxx , hopefully not the patient, is dead

• Celebrex 200mg/D max dose

• Celebrex is a sulfonamide

• Look close-they will soon be gone

• Don’t prescribe them

GONE

9/19/2016

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Ibuprofen-The Best of theNSAID’s

• Cheap• Flexible

dosage

Schedule

Use of topical NSAID’s for acute painother than cataract surgery is:

OFF-LABEL

Diclofenac 0.1% (Voltaren-Ciba)

• Generic associated with corneal melting (never able to prove association)

• Pain and inflammation associated with cataract surgery

• Dosage: QID

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11

Flubiprofen 0.03% (Ocufen-Allergan)

• ONLY INDICATION-Interoperative miosis

• 1 drop Q 30min X 4 total 2

hours prior to surgery

Ketorolac 0.5% and 0.4% (Acular,Acular PF, Acular LS-Allergan)

• Really know how to extend a patent

• Only NSAID indicated for ocular allergy

• Marked stinging

• Dosage: QID

Brofenac 0.09%(Bromday – B and L)

• First “once daily” post-op cataract treatment

9/19/2016

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Nepafenac 0.1% (Nevanac-Alcon)

• Only “Pro-drug” NSAID

• Not available as generic

• Dosage TID

Analgesic Pharmacology

• Tylenol/Acetaminophen/(N-Acetyl-P-aminophenol)/APAP

• Unknown central mechanism

• Anti-pyretic: Hypothalmus

• No anti-inflammatory effect@@@@

• No inhibition of platelets@@@@

Acetaminophen is a Safe Drug?

Drug of Choice (DOC) in:

• Children

• Viral induced fever

• Pregnancy@@@@

• Nursing mothers

• No GI distress

• No Increase in Bleeding?@@@@

9/19/2016

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If They Like to Drink, Think TwiceAbout Acetaminophen

• Acetaminophen associated with liverfailure in alcoholics (>3 drinks/d)

• Liver failure = decreased drugmetabolism = overdose

• Reduced vitamin K clotting factors = increased bleeding

• Max adult dose = 4gm/D = 8 extra-strength Tylenol per 24 hours (2.6gms?)

• 5% of metabolites hepatotoxic

APAP Liver Metabolism

1. Major pathway —Majority of drugis metabolized to produce a non-toxic metabolite

2. Minor pathway —Produces a highly reactiveintermediate (acetylimidoquinone) that

conjugates with glutathione and is inactivated.

• At toxic APAP levels, minor pathway metabolismcannot keep up (liver’s supply of glutathione is limited), causing an increase in the reactive intermediate which leads to hepatic toxicity and necrosis

Acetaminophen toxicity

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Medicinesfor Fever or Pain Relief

Acetaminophen Dosing Chart

41

Centrally Acting Agents

• React with receptors in theCNS

• Interrupts both the pain message and its emotional response

• Opioids – e.g., morphine, oxycodone, codeine –mechanisms poorly understood

• Endorphins– naturally manufacturedby brain, they may blockperipheral transmitters orhyperpolarize neurons

Receptortype

Location Effects

μBrain, spinal cord

Analgesia, Respiratory depression, euphoria, addiction, ALL pain messages blocked

Analgesia, sedation, all non-thermal pain messages blocked

Analgesia, antidepression, dependence

κBrain,spinal cord

δBrain

Most strongly binds

morphine

Best betfor a safeanalgesic

9/19/2016

15

MU Opioid receptors

• Classic morphine receptor• Located in brain and spinal cord• Stimulated by endogenous endorphins• Binding of drug to these receptors produces

analgesia/sedation/decreasedBP/itching/nausea/euphoria/decreasedrespiration/

• Effects decline as drug tolerance develops• Narcotic antagonists block these receptors

Kappa Opioid receptors

• Novel receptors

• Stimulation relieves pain, but produces nausea and sweating (dysphoria)

• Endogenous transmitters are dynorphins

• Located in the periphery by pain neurons

• Not associated with euphoria response

Delta Opioid receptors

• Stimulated by endogenous enkephalins

• Produces “ischemic preconditioning”

• Stimulation induced protective increase in blood flow to tissues surrounding an ischemic area

• May have cardioprotective effect

9/19/2016

16

Opiate Analgesics

• Block central pain receptors, reduce perception of pain-They feel pain, but don’t care

• Inhibits descending pain pathways

• Allergic to one opiate, allergic to allopiates

• Know your schedules

• Schedule II, high abuse, V= low abuse

• Know your side-effects/autonomics

Side-effects

• Respiration-sleep apnea/COPD

• Urinary tract/the bigprostate/incontinance TX

• GI Tract: The food stops here

• Interaction with other anticholinergics/

• DRY/DROWSINESS/GLC

Is Constipation a Side-effect orIndication-Depends on your point

of viewINDICATION SIDE-EFFECT

9/19/2016

17

Tolerance and Dependence

Tolerance

• Tolerance is a diminished responsiveness to the drug’s action that is seen with many compounds

• Tolerance can be demonstrated by a decreased effect from a constant dose of drug or by an increase in the minimum drug dose required to produce a given level of effect

• Physiological tolerance involves changes in the binding of a drug to receptors or changes in receptor transductional processes related to the drug of action

• This type of tolerance occurs in opioids

Dependence• Physiological dependence occurs when the drug is

necessary for normal physiological functioning – this is demonstrated by the withdrawl reactions

• Withdrawl reactions are usually the opposite of the physiological effects produced by the drug

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18

Withdrawl ReactionsAcute Action

• Analgesia

• Respiratory Depression

• Euphoria

• Relaxation and sleep

• Tranquilization

• Decreased blood pressure

• Constipation

• Pupillary constriction

• Hypothermia

• Drying of secretions

• Reduced sex drive

• Flushed and warm skin

Withdrawl Sign• Pain and irritability

• Hyperventilation

• Dysphoria and depression

• Restlessness and insomnia

• Fearfulness and hostility

• Increased blood pressure

• Diarrhea

• Pupillary dilation

• Hyperthermia

• Lacrimation, runny nose

• Spontaneous ejaculation

• Chilliness and “gooseflesh”

COMBINATION OPIATEANALGESICS

• Codeine +

• Hydrocodone +

• Oxycodone +

• Oxycodone +

• Tramadol +

• Tylenol 1,2,3,4

• APAP = Vicodin

• ASA = Percodan

• APAP = Percocett

• APAP = Ultram

PROPOXYPHENE = DARVON• Relatively poor analgesia

• Lots of sedation

• Neurological side-effects

• Use if you want them to

sleep a lot

• Darvocett N 50 and 100 were the best of group = propoxypene napsylate

with acetaminophen

GONE

9/19/2016

19

Which Tylenol with Codeine ShouldYou Use?

All contain 5 grains of APAP (325mg) WITH:

• Tylenol #4 = 1 grain (60mg) codeine

• Tylenol #3 = 1/2 grain (30mg)codeine@@@@

• Tylenol #2 = 1/4 grain (15mg) codeine

• Tylenol #1 = 1/8 grain 7.5mg) codeine

A CLINICAL MOMENT

36 Y/O construction worker suffers an orbital blow-out fracture, complains

about severe pain, requests painreliever

Write him a prescription foracetaminophen with codeine-give himthe maximum pain relieving dosage of

the drug

John Doe 7/20/00100 Low Life Ln.

Acetaminophen with Codeine #3

#20 (Twenty)

SIG: i-ii tabs q 4-6H prn pain

Refills: Zero

B. Onofrey MO 0182597

9/19/2016

20

Oxycodone, The “BIG GUN”

• With ASA = Percodan

• With APAP = Percocett

• Schedule II drug = Highabuse

• Better alternative with a schedule III drug

5MG/325MG

HOW ABOUT ULTRAM?• A synthetic opiate with slightly

reduced opiate side-effects

• NOT for opiate allergics

• Not for addicts-Inducewithdrawal

• Has produced addiction

• 50-100mg QID prn-max 400mg/D

• >65, then 300mg/D max

• Ultracet, like Tylenol #3

Ibuprofen/acetaminophen

• Incredible synergism@@@@@@

• Non-narcotic drugs

• Non RX drugs

• Inexpensive

• Monitor for sensitivity to either drug

• No motrin in pregnancy/with blood thinners/GI problems/renal disease/CHF

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Ibuprofen/AcetaminophenIndication/dosage forms

• Indications:

• Mild to severe pain

• Dosage forms

• 400-600mg motrin with 500-1000mg acetaminophen (Do not exceed 4 gms acetaminophen/day)

• No acetaminophen for persons thatregularly consume daily alcohol

Who gets Post-herpeticNeuralgia

• Immunocompromised folk

• The elderly

• Best treatment is prophylactic TX

Prevention is Critical

• Acyclovir

• Famcyclovir

• Valcyclovir

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Manage Potential Post-herpeticNeuralgia

• Oral acyclovir 800mg 5X daily

• Valacyclovir 1000mg TID

• Famcyclovir 500mg TID

• Zostrix creme 3-4 times daily

• Low dose tricyclic antidepressant-amitryptyline 25mg/day

Anti-depressant for pain relief?

• Very good neural pain relief

• “GOOD” anticholinergic side-effects

Neurontin: The New “Big Dog”for chronic pain

• Huge dosage range: 100-5000mg/d

• Must start slow

• Must give enough

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HEADACHE DIAGNOSISP - Provokes, Palliates Q - QualityR.- RegionS.- Severity, Associated signs/symptoms T

- Timing1. Onset2. Frequency3. Duration

The Headache Patient

Selective Serotonin Receptor Agonists

• Imitrex (sumatriptan)• Zomig (zolmitriptan)• Amerge (naratriptan)• Maxalt (rizatriptan)• Axert (almotriptan)• Frova (frovatriptan)• Relpax (eletriptan)• Treximet (sumatriptan/naproxen)

Seratonin (5HT Agonists)

• The “triptan drugs”

• Sulfonamides-beware ofallergy\Beware of heartdisease

• Prevent BV Spasm(Vasoconstrictive effect)

• Inhibit trigeminal nerve

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A PRACTICAL OPTOMETRIC HEADACHE APPROACH

Selective Serotonin Receptor Agonists

• Efficacy: if first triptan does not work, try another – may require trial and error

• Onset: injection – 10-15

minutes nasal spray – 15

minutes

troche – no faster than oral tablets

• Route: nasal spray or injection for N/V

• Duration: longest acting – Frova andAmerge

Needle-Free Sumatriptan

• Sumavel DosePro – subcutaneous 6 mg injection

• Uses high-pressure burst of nitrogen gasinstead of needle

• Works as fast and as well as needle injection

• Causes more redness, swelling, bleeding andbruising than needle injection

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MIGRAINE TREATMENT

Prophylactic (Preventive)a. Beta blockersb. Tricyclic antidepressantsc. Nonsteroidal anti-inflammatory drugsd. Calcium channel blockerse. Monoamine oxidase inhibitors: Nardilf. Anticonvulsants: Depakote, Depakene, Topamax

THE HEADACHE PILLS-NEVER USE THEM

• HA is a DX of exclusion

• Don’t cover-upundiagnosed pain

• We must exclude other causes, but WE don’t make the final DX

• Let PCP or neurologist manage pain AFTER final DX made

IN HA DX IS EVERYTHING

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SYMPTOMS AND SIGNS OF ORGANIC DISEASE

SYMPTOMS AND SIGNS OF ORGANIC DISEASE

Rheumatoid disease

• A disease of inflammation and autoimmunity

• Affects joints-localized to the synovial membrane

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Cause of RA

• Genetic predisposition: Rheumatoid factor

An IgM antibody (auto-immune) against IgG

Present in most RA patients

Produced by B-cells (humoral anti-body) insynovial fluid

Progression• RF factor/IgG complex triggers

complement = tissue damage

• Damage attracts cellular response-PMN’s and macrophagees

• Pannus formation in joint : PMN’s (+)macrophages (+) fibroblasts form scartissue in joint

• IL-1 and TNF alpha produced by pannus stimulate osteoclasts from macrophages and produce bone reabsorption = joint damage

Meet the DMARD’s

• D – Disease

• M – Modifying

• A – Anti-

• R – Rheumatic

• D - Drugs

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Indications

• Relieve or reduce pain

• Improve function

• Reduce joint inflammation (swelling, tenderness & reduced ROM

• Prevent joint damage and deformity

• Prevent disability

• Improve quality of life

• More toxic than NSAIDS

Categories of DMARD’s

• FIRST GENERATION

Gold compounds: aurothioglucose

Action: Inhibit macrophage migrationand phagcytosis

Toxic: Colitis and reduced immunity

Required weekly IM injections


• ORALS: 2nd generation

Hydroxychloroquine

Leflunomide

Methotrexate

Sulfasalazine

Azathioprine

Cyclophosphamide

Cyclosporine

Minocycline

Penicillamine

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Methotrexate and leflunamide

• Cytotoxic B/T cell inhibitors

• Block pyramidines (Inhibits DNA synthesis)

• Prevent B and T cell proliferation and therefore prevent formation of RF

Hydroxychloroquine/Plaquenil

• Inhibits lymphocytes and IL-1 production

• Dose : 200-400mg/D

• Monitor for maculopathy

• Occurs rarely/increased risk after cumulative dose of 700gm (>5yrs TX)


• BIOLOGICALS (Injectables)

• 3rd generation TNF alpha antagonists

Abatacept : Orencia

Adalimumab : Humira

Anakinra : (Kineret)

Inflixamab : Remicade

Rituximab : Rituxan

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Biologicals

• Prevent bone absorption and joint deformation

• Protein compds-must be injected

• Cost: $10K/yr•Adverse effects:

Liver toxic

Opportunistic infections

Death

RA TX

OLD WAY

• Tx conservatively

• With NSAIDS-DMARDS only if severe

NEW WAY

• TX aggressively with DMARDS ASAP-”window of opportunity is early in TX

• Combination TXis common

Steroids and RA

• Block production of IL-1

• Dramatic , rapid suppression of inflammation

• Short term, intermittent use only –due to SE’s

• Used until DMARDS take effect

• Local joint injections can producedegeneration of cartilage

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Thank You

8/10/2016

1

Billing and Coding -Just the Facts, Mam...JOE W DELOACH, OD, FAAOCEO, PRACTICE COMPLIANCE SOLUTIONSCLINICAL PROFESSOR, UHCO

Disclosures – Joe DeLoach, OD, FAAO

• Vision Source• Alcon

Laboratories• Carl Zeiss

Meditec• Optos• Diopsys• Kowa

• OfficeMate• Marco• TSO• NVision• Clienman

Partners• Vision Trends

• Essilor of America

• Pearl Vision / SNAPP• Vision West• UHCO, RSO, UAB,

Berkley, etcand other optometry schools

I Have Received Honoraria From or Served as a Consultant for:(Partial Listing)

Practice Compliance Solutions, LLC – President and CEO (no financial interest)Clinical Professor – University of Houston College of Optometry (opinions do not necessarily reflect the views of the University)

Over half the state optometric

associations

ADDITIONAL DISCLAIMERS

Policies presented or discussed in this presentation are specific to the State of Nevada and predominantly based on Medicare rules. Individual payer policies are unique, regional and sometimes not clearly published.

Any fees presented in this presentation are the average North Texas Medicare allowable fees. Fees presented are in no way designed to state any acceptable fee or suggest to any provider they change their fees

8/10/2016

2

MENU

Why This Is Such a Mess Top Reimbursement Problems (why you

are likely to get audited) Top Medical Records Documentation

Problems (why you are likely to lose an audit)

Why This Is Such a Mess

THE HISTORICAL PROBLEM WITH CODING AND

DOCUMENTATION INFORMATION

TRUTH!!(BLURRED TRUTH)

Who are the “experts”?

8/10/2016

3

AOA’s Webinar by their “coding experts” on use of OptoMap and fundus photography (92250)

Encouraging incorrect use of the -25 modifier by a certain “coding expert” in an attempt to bypass edit rules

Instructions from instrument companies to bill FAF as 92499 Using OCT 92132 for billing pachymetry “Ways around” the -59 modifier to bill fundus photos and

SLOs during the same encounterWidespread mis-information regarding the ophthalmologic

codes in an attempt to push coding lectures on EM codesOnly black ink…it’s the LAW

A Few from MANY Bad Examples….

Could go on and on and will over the next few hours

So why believe me? I have lectured nationally on ethical coding for 25 years I am CourseMaster for the UHCO Professional Ethics Course (have been

since it’s introduction) I served on the Trailblazer CAC for a over a decade and now on the Novitas

CAC for eight years (CACs make Medicare policy!) I served on the TOA Third Party Committee for 20 years and as their

consultant “emeritus” for the past 5 years I direct a company that performs audit and billing services – we are

responsible to our clients to know what is legal / correct and what isn’t I audit for medical payors (including Medicare) Unless I say it is my opinion, I will back up anything I tell you from

the “TRUTH” sourcesOr don’t…you decide

Sources of Reimbursement Truth!

www.cms.gov (Medicare)https://noridianmedicare.com Jurisdiction JE (that’s you) Carrier

www.insert-your-payor.comCPT and ICD-10 Manuals

www.CodeSAFEPLUS.comwww.practicecompliancesolutions.com

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The Bipolar World of Coding ExpertsPRACTICE CENTRIC BILLING MAXIMUM use of examinations,

testing and technology Twist the system in an attempt to get

around the rules Do what puts the most money in the

bank

RESULTIndefensible care – often “worthless” per CMS (more later)Massive audit exposureDoctors getting severely hurtSleepless nights

PATIENT CENTRIC BILLING Medically necessary use of examinations,

testing and technology 95% of rules are pretty clear – just follow

them Do what’s right for the patient and the

money will follow

RESULTDefensible, medically necessary careMinimal audit exposureVery likely to make as much money just doing what’s rightSleep like a baby

“Practice Centric Billing” has forced the payer world’s hand –the focus is now on

fraud and abuse

Background – Fraud and Abuse2010 - Patient Protection and Affordable Care Act (ultimate oxymoron) made the F/A programs mandatory for any Medicare or Medicaid payer and made it clear the government held doctors responsible for “knowing and abiding by” the five Federal Fraud and Abuse statutes (even though you always have been legally responsible)

So who in the room can name them?That’s what I thought…we will in a bit!

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5

Summary of the intense focus on fraud and abuse

It’s all about doing what is right for the patient, the right way, without any influence

from real or perceived monetary gain

And doctors aren’t doing that?

2013 estimates of loss from fraud and abuse in the Medicare system alone

$65 BILLIONguess they aren’t…

2015 OIG Work Plan

77…count them…77 health care items

Fraud and abuse cited by the OIG as the number one concern in health care today

Please listen! Not the uninsured, not ACAs, not Medicaid expansion IT IS DOCTORS, INCLUDING OPTOMETRISTS, ABUSING HEALTH CARE REIMBURSEMENT!

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ONE OF THE SPECIFIC OIG ACTION ITEMS

Increase investigation of ophthalmologists for

“inappropriate and questionable billing practices”

Don’t get excited…we use the same codes and that is what they are looking at!

ophthalmologists AND optometristsOptometrists not a problem??CERT says so - to the tune of

$175 MILLION(more on that later!)

And WE are to blame… For pushing “medical model” For pushing “turning medical” For pushing “return on investment”

And NOT properly teaching the concepts of reason for the visit, medical necessity, medical documentation and medical

ethics in general

But I’m Just Spouting My “Tired Outrage”

I’m Wrong? The payers have recruited help!

“show Medicare and Medicaid recipients how to protect against, detect and report fraud”

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So, how much of a liar are you?

Well I contend most all of you are!!!

Wow, Joe….that’s pretty nervy coming from an old, short guy from Texas

Well, I told you I would prove what I say, so here it is!

“In submitting this claim for payment from federal funds, I certify that 1)the information on this form is true, accurate and complete 2)I have familiarized myself with all laws, regulations and program instructions available from the Medicare contractor 3)I have provided or can provide sufficient information required to allow the government to make an informed eligibility and payment decision 4) this claim complies with all Medicare program instructions and…” lists all five Federal F/A laws you can’t name!

Ever read what you sign?

But this is news to me!

“My signature is to certify that the foregoing information is true and accurate. I understand that any false claims or statements or concealment of a material fact may be prosecuted under applicable Federal and Stark laws.”

GOOD LUCK TRYING TO SAY YOU DIDN’T KNOW BETTER!

8/10/2016

8

False Claims ActAnti-Kickback StatuteProvider Self-Referral LawExclusion StatuteCivil Monetary Penalties Law

Five Main Fraud and Abuse Laws

If you don’t know what these laws say, you need to do some personal homework or I can make it easy

for you with the PCS Fraud and Abuse Manual

Let’s be clear…

Not KNOWING and not FOLLOWING ethical billing and medical records documentation is no longer just a bad

idea…it is a potential criminal violation! The next time coding “experts” cannot back up what

they are telling you, or Equipment and practice management folks put making

money in front of medically necessary and ethical patient care, or

You’re billing something a certain way because your colleague said – “it works, I’m getting paid!”

RUN FROM THE ROOM!!!

The Government’s Response to All This Foolishness? The laws haven’t changed – just the profitability of

enforcing them has become crystal clearHealth care reform – major emphasis on ABUSE and

especialy FRAUD (fraud has a new definition!)

Change in False Claim Statute language from “knows or has reason to know” to “knows or should know”

Qui Tam – The Whistleblower ActCMS new audit program – “Predictive Analysis”

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9

The Age of Audits

Optometry has never been a big “target” – has that changed?

If you are filing claims, you are a target!

And some of your colleagues are making you a bigger target!

Oh really? For example….• Fundus photos on 88% of new Medicare

encounters• VEPs on 59% of new Medicare encounters

And who taught them to do this stuff? WE did! Push medical, turn medical, “x” number of procedures per month will yield “$”

ODs aren’t getting burned? Just a few I was involved with in 2015$46,541.00 payback and termination of contract with Aetna$56,500.00 payback and termination of contract with EyeMed$111,892.00 MC payback (initial amount was >$500K)$167,231.00 payback and fines and exclusion from Medicare and Medicaid

ALL FOUR OPTOMETRISTSI’ll show you more of what the real crooks are doing later!

What Did PCS Training Audits in 2013-15 Reveal?After evaluating THOUSANDS of patient encounters:

Average payback on “mini” audit (20 records) - 28.5% of receipts

Average 5-year recoupment penalty -$397,650.00

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From there it only gets worse.

MUCH worse!

Examination services $ 57,875,452Diagnostic services $114,388,586DMERC services $ 3,491,580

$175 MILLION

Per CERT 2013 ResultsIMPROPER Payment to Us

THINK THEY MAY WANT IT BACK???

#1 Insufficient documentation (65.5%)#2 Incorrect coding (35.7%)#3 NO documentation (4.3%)#4 Lack of medical necessity (33.6%)

In over 70% of denials, medical record documentation was an issue – so we will

talk about THAT more later

And CERT tells us why!

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In order… the culprits in our world

1. Medicare2. Aetna3. VSP4. BCBS5. EyeMed

One of the biggest optometric “stings” in

2013-15

VSP auditing (term used loosely), especially

medically necessary contact lens billings

Types of Audits

Historical: Post-Payment (“Pay and chase”)Medical Review – review of medical record to evaluate

record documents medical necessity for money already paid Statistical Monitoring – contracted agent (CERT, RAC)reviews

claim based on statistical analysis of billing patterns and “mini” samples

The Future (October 2016): Predictive Analysis (“Guilty until proven innocent”)

Records review by cognitive software – “predicted” improper payment withheld until medical record produced

Audit Defense

The best defense? A great offense!First, be an ethical doctorKeep exquisite medical recordsKnow your REGIONAL payor rules and policiesCodeSAFEPLUS (www.codesafeplus.com)

Keep updated by signing up for payer website listserves and newsletters

Routine records audits – internal and external

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So now you hopefully believe you have to do this the right way.So what is “the right way”?

Let’s look at the most common billing and coding

myths and legends

Myth #1 Most all optometric encounters are comprehensive evaluations

Do whatever you want but all you can bill for is medically necessary services based on the reason for the visit

The medical health care world performs symptom(s) driven or problem specific care –optometry is confused!

Actually, that is EXACTLY what I’m saying.

Unless you have to fulfill some mindless requirements of your state law or a vision plan, you perform a symptom oriented exam just like the rest of the medical world does (example)

You’re kidding right – you’re not saying a patient comes in stating their only concern is a “bump” on their eyelid and all I do is diagnose and treat the eyelid problem –

not a comprehensive history, refraction, cover tests, ductions, screening visual fields, dilated internal, and give

them three glasses prescriptions?

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13

So how are we doing with that concept?

SERVICE CODE CMS AVERAGES

OPTOMETRYAVERAGES

92004 / 14 56% 81%92002 / 12 44% 19%Level 2 E/M New /Established 20% / 9% 5% / 16%Level 3 E/M New /Established 44% / 57% 38% / 48%Level 4 E/M New /Established 25% / 28% 54% / 34% Level 5 E/M New /Established 8% / 3% 2% / 2%

We have taught optometry to “go” medical but didn’t teach them how medical works.

End result…the chart above and one to follow

The reasons / excuses for disagreeing with me - that we SHOULD always do comprehensive care gathered from my 2013 Texas Ethics Course where I presented this concept

This is the way I was taught in school I’ll be sued if I miss somethingMy patient expects a full examinationOptometry is different…. If I don’t see them every year, I might lose an optical sale to

Warby Parker (REALLY told me that! OUCH!)

This Concept Is NOT Complicated and For One Time I Will Just Say – I AM RIGHT!

1. Symptoms2. Patient history (not in Medicare, actually most payers)

3. Signs from the examination (not in Medicare, actually most payers)

4. Physician direction5. Another physician or patient direction

Per CPT, what can qualify as a reason for the visit

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Is It Vision or Medical - It’s easy…NEW PATIENTBased on symptoms leading to medical diagnoses, or…Another physician or patient directionESTABLISHED PATIENTYou are in control – based on physician direction

OTHERWISE IT IS NOT A MEDICAL ENCOUNTER!And “turning medical” is insurance fraud!

One more point….

“Blurred vision” does NOT justify a medical encounter unless the reason for the blurred vision is wholly or in part caused by a medical condition.

If it is, you need to state so in the medical record

Blurred vision complaint with a billed diagnosis of dry eyes, cataracts, AMD etc when the patient corrects refractively to normal or near normal vision is a common audit denial

Here is the ONLY RuleMedicare says you cannot charge

Medicare MORE than your usual and customary fee for the same service

THAT’S IT….PERIOD

Myth #2I Have to Charge Everyone the Same Fee

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PROCEDURE YOUR UCR MEDICARE ALLOWABLE

MEDICARE PAYS YOU

UNITED HEALTH PAYS YOU*

92004 $69 $139 $55.20 (20% of $69)

$143*

92004 $139 $139 $111.20 (20% of $139)

$143*

92004 $159 $139 $111.20(20% of $139)

$143*

* Assumes United Health Care allowable is $143

Medicaid pays $89 for 92004 – DOESN’T MATTER

VSP pays $79 for 92004 – DOESN’T MATTER (usually)

You charge $49 for a wellness exam – SILLY, BUT…

This is how it works….

DON’T MIX UP THIS ISSUE WITH FEES FOR NON-MEDICAL CARE!

And what about same day discounts? Legal or just professionally

disgusting?

Depends….

Are supposed to be A way to offer discount services to those with “significant financial

limitations” Utilized on a limited basis – except in charity / indigent care clinics

Cannot be Office policy Advertised to your patients or the public

Must bePresented to each patient individually

Per the Anti-Kickback Statute -Same Day (Prompt Pay) Discounts

VERY IMPORTANTApplies to medically necessary care, not

wellness care

8/10/2016

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Re: OIG Advisory Opinion No. 08-03Dear [name redacted]:We are writing in response to your request for an advisory opinion regarding a proposed arrangement by which a health care system would provide prompt pay discounts to Federal health care program beneficiaries and other insured patients…

III. CONCLUSIONBased on the facts certified in your request for an advisory opinion and supplemental submissions, we conclude that (i) the Proposed Arrangement could potentially generate prohibited remuneration under the anti-kickback statute, if the requisite intent to induce or reward referrals of Federal health care program business were present

But don’t just believe me…

Which you are doing when you offer this to people WITHOUT financial need

If prosecuted, Medicare can adjust ALL your Medicare payments for ALL services by your same day discount percentage OVER THE PAST FIVE YEARS and request the sum paid back to them within 30 days

Don’t pay it, your Medicare fees will be withheld until you pay off your debt to the government

Go ahead….test the system

Actually you can deliver it…BUTYou cannot BILL the payer for services they feel

are not medically necessary (you can AND SHOULD charge the patient if they agree to pay for the non-covered service before it is delivered)

Per CPT, you cannot bill for services where the data is not useful

You cannot bill for “worthless services”

Myth #3In the final analysis, I can deliver whatever care I deem to be medically necessary

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“Worthless” – Per CMS

is not accepted as safe and effective is not supported in peer-reviewed medical literature is not medically necessary in a specific case or specific diagnosis is furnished at a level, duration, dosage or frequency not

appropriate for a specific patient or clinical condition is not furnished consistent with standards of care is furnished for patient or provider convenience is a device that is not approved by the FDA is a test or service now considered obsolete

SUMMARY #3

YOUR medical necessity determination and the PAYER’s may not be the same – VERY commonly

You determine medical necessity, someone paysCANNOT make a patient pay for

bundled/edited services (ex. Photo and scanning laser during same encounter)

Screening services are NEVER medically necessary (with one exception)

Isn’t it all about payment policies?

Jurisdiction E – Noridian Medicare

L34194 Blepharoplasties L34203 Cataract surgery

No draft policies, no future policies, no potential policies

Is that good or bad?

8/10/2016

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Eye Opening Concept?

Myth #4Dilation is not an issue

1. Dilation IS an issue if the reason for the visit warrants medical necessity for dilation based on preferred practice patterns

2. Dilation IS an issue based on the payer – see your provider manual (even vision plans)

3. Dilation IS an issue based on the appropriate service code determined by the reason for the visit1. Intermediate ophthalmologic code (920X2) – may include2. Comprehensive ophthalmologic code (920X4) – usually includes3. Evaluation and management codes (992XX) – ALWAYS a

REQUIREMENT when counting the internal examination key elements

And what if #2 and #3 don’t jive?

And pictures, especially OptoMapsubstitute for dilation?

Sorry, I can make all the rationale arguments it should be right along with you but in 2016 the answer is unequivocally

NO

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Myth #5Over-Use / Incorrect Use of Modifiers

In general: There are dozens and dozens of modifiers – we deal

with only a handful of them Easy…you literally only need to know about a very

small number of themSome of them cause SIGNIFICANT problems for

you….or can

Let’s Start With The Evil One - 59Evil you say? Yep – CMS and the OIG think this one is!

59 ModifierTHE most abused and actively audited modifier in health care. It does WHAT? And optometry likes it WHY?

Most coding folks don’t read far enough where it says:“It is not appropriate to use the -59 modifier unless dealing with serious ocular conditions where delay in obtaining information from two edited procedures could result in acute harm to the patient”

GLAUCOMA?Good luck with

that!

24 - A problematic one you must understand how to use

-24 ModifierThe second most abused and actively audited modifier. Two problems:1. Certain “coding experts” are teaching to add the -25

modifier to all office visits to “bypass” the rules. That is called fraud. Three words in coding start with “F” -fraud, felony, you are f…

2. Providers do not understand that the office visit is included in the fee for a surgical procedure with only one exception

8/10/2016

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Modifier -25

CLEAR ENOUGH?

Oh, but Joe…but I ALWAYS have to evaluate the patient to

determine the need for surgery!RIGHT – and that is included in

the surgical fee!!!

The OIG felt abuse of the -25 is such a health care fraud issue THEY decided when that one exception was:

“We (NOT you…my edit) will determine whether providers used modifier –25 appropriately. In general, a provider should not bill evaluation and management codes on the same day as a procedure or other service unless the evaluation and management service is unrelated to such procedure or service.”

A “new” picky one – Modifier 52

Not really new…just now enforced Simple concept – you cannot be paid a bilateral

service fee when you only did the test on one eye Not as simple concept – you cannot be paid a

bilateral service fee when it was not medically necessary to conduct the test on both eyes

Most diagnostic procedures are bilateral except radiology codes and scanning laser

Identifying Modifiers

You already know them…

RT/LTE1/E2/E3/E4GWThe ABN modifiers: GA, GX & GY

Then there are tons of surgical modifiers – about the only one that would apply to us is the multiple procedure modifier - 51

Aren’t these no longer necessary since the ICD-10 codes specify laterality and location?

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Myth #6Ophthalmologic vs Evaluation and Management Codes – use which one?This is actually VERY simple! 1. You can ALWAYS use an evaluation and

management code – conduct a problem oriented examination based on the reason for the visit and add up what you did (but good luck getting it right!)

2. You can ONLY use an ophthalmologic code when your service meets the definition and description of the code (Means what? Next slides…)

When can I use 92002 / 12?When it is medical necessary based on the reason for the visit to complete the elements of the examination required in the description and definition.DESCRIPTION: “Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, new/established patient.”DEFINITION: “An evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy."

92002 / 12Reason for the visit must justify:

1. Medical evaluation2. History3. General medical observation4. Evaluation of external eye and adnexa

And “complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis” means what?

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When can I use 92004 / 14?Same rationale…DESCRIPTION: “Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, one or more visits”DEFINITION: “Includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, ophthalmoscopic examination, usually with cycloplegia or mydriasis, and tonometry. It always includes initiation of diagnostic and treatment programs”

92004 / 14Reason for the visit must justify:1. Medical evaluation2. History3. General medical observation4. External and internal examination (usually dilated)5. Gross visual fields6. Basic sensorimotor (binocular) assessment7. Diagnosis and treatment plan

The Problem

Coding “experts” – create your own need Optometrists have been programmed by the vision

companies to think that the ophthalmologic codes are vision codes (and that they provide medical care!)

Optometrists do not understand that every encounter is not a menu driven full examination – every encounter is a problem specific examination

Evaluation and management codes are a huge audit issue –number one most audited codes in all of health care – and the comprehensive ophthalmologic is now right behind them

CMS stats…66% of all evaluation and management codes are submitted incorrectly

and within that 66%, 90% are incorrectly up-coded

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SERVICE CODE CMS AVERAGES OPTOMETRYAVERAGES

92004 / 14 56% 81%92002 / 12 44% 19%Level 2 E/M New / Established 20% / 9% 5% / 16%Level 3 E/M New / Established 44% / 57% 38% / 48%Level 4 E/M New / Established 25% / 28% 54% / 34% Level 5 E/M New / Established 8% / 3% 2% / 2%

Remember how we’re doing?

AHHHH!!! But can you tell us something REALLY important? Well, I just did, but…

Turtles can breath through

their butts

Myth #7Global Surgery Periods24 / 79 and 54/55 Modifiers

24/79 Used when providing services to a patient under your Global Surgery Fee Period for conditions unrelated to the surgery – 24 goes with office visits and -79 with diagnostic services

54/55 Used for split reimbursement for postoperative care under a formal comanagement agreement

Good news…global surgery periods are being phased out – all gone by 2019

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And, seemingly little known fact…

The Global Surgery Fee Period applies ONLY to the operating surgeon. An optometrist is not bound by the Global Surgery Fee Period restrictions unless they enter into a formal comanagementagreement with the operating surgeon.

Myth #8LOTS of testing is good…and necessary

The Sources of the Problem BAD practice management advice. Translation: Greed BAD instrument company advice. Translation: Double

Greed Unsure of diagnosis / “chasing unicorns” Defensive medicine – confusion between medical

necessity, preferred practice patterns and “standard of care”

“Confirmatory” Testing – Just a few examples to make you think The American College of Physicians estimates excessive testing costs

the health care system between $200-$250 BILLION every year (2012 number – and just getting worse)

The American Cancer Society - Dr. Brawley states the $10 stool test has been shown to save lives equally, but in the United States, the $3,000 colonoscopy is mostly commonly used. “Everyone is getting the expensive test, even though the cheaper test is better. But the cheaper test involves handling shi… and no one can make money off of it,” Brawley said.

Closer to home…In the United States, despite the barrage of increased technology, much likely worthless, the overall incidence of blindness from glaucoma has not changed in over two decades

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Forget all that…bottom line -over testing is just flat WRONG

Per CMS:Medical record documentation must clearly indicate rationale which supports the medical necessity for performing each test. Documentation should also reflect how the test results were used in the patient’s plan of care.

It would not be considered medically reasonable and necessary to perform any diagnostic procedure simply to provide additional confirmatory information for a diagnosis or treatment which has already been determined. (my emphasis added)

Remember, just the FACTS….

Medicine is NOT menu driven care. A particular disease or diagnosis does NOT support an exhaustive list of diagnostic tests just because you have the instrument.

Biggest problem in optometry – significant over testing for glaucoma. Sorry, a patient with a family history of glaucoma does not routinely need a scanning laser, fundus photo, visual field, pachymetry, gonioscopy, anterior segment OCT, color vision test, VEP, and ERG –much less all repeated six months later.

And those tests and the crooks ….CPT PROCEDURE AVERAGE OD

UTILIZATIONAVERAGE PAYER MEDIAN USAGE

REAL OD EX.N=2711

68761 PUNCTAL PLUGS 3.2% 6.1% 227% (6154)68801 PUNCTAL DILATION / IRRIGATION 0.3% 1.6% 51.6% (1400)76514 CORNEAL PACHYMETRY 1.0% 5.1% 24.7% (723)92020 GONIOSCOPY 0.15% 6.3% 41.7% (1130)92025 CORNEAL TOPOGRAPHY 0.17% 5.7% 76.2% (2066)92060 SENSORIMOTOR EXAMINATION 0.15% NO DATA 133% (3606)92083 VISUAL FIELDS 8.3% 18.3% 85.7% (2323)92133/4 SCANNING LASER 5.6% 16.8% 45.2% (1225)92225/6 EXTENDED OPHTHALMOSCOPY 1.5% 4.3% 131% (3551)92250 FUNDUS PHOTOGRAPHY 12.5% 22.6% 84.2% (2283)92283 EXT. COLOR VISION EXAMINATION 0.04% NO DATA 37% (1003)92285 EXTERNAL PHOTOGRAPHY 1.2% NO DATA 99.4% (2695)92286 SPECULAR MICROSCOPY 0.54% 5.9% 41.5% (1125)95930 VISUAL EVOKED POTENTIAL 0.04% NO DATA 42.9% (1163)

THIS WAS IN 2013 – MANY HAVE BECOME FAR CRAFTIER SINCE THEN!

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Myth #9“Substitution” is OK

Examples of Fraudulent Substitution Billing an office visit instead of surgical procedure Billing anterior segment laser for pachymetry Billing anterior segment laser for gonioscopy Billing FAF as scanning laser or unlisted code “Diagnosis” substitutions

EVERY TIME IN ORDER TO MAKE MORE MONEY!

OK…so you’ve been accusing us of bad

medical records for over an hour. What’s that all

about?

Top Medical Records Documentation Errors

(in no order or frequency or severity)

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Per Frank Cohen, EMG Inc.National audit authority

Top Five Reasons Doctors Lose Audits1. No documentation2. Inadequate documentation3. Lack of medical necessity (per payment policy)4. Incorrect / non-specific diagnosis code5. Provider issues (lack of signature, attending physician

not the billing physician)

“You’re going to get audited, so…”

This one is easy – can’t read it, automatic denial

EXTREMELY difficult audit defense Documentation is next to impossible with ICD-

10

Problem #1Illegible Paper Records

CPT states that on established visits, it must be clear to an auditor that the attending physician PERSONALLY conducted the HPI and applicable history elements were reviewed and updated. You have two choices: Make changes, if present, to the patient’s history and hope that

an auditor recognizes the changes made (without the previous record? Good luck!)

Make a note in your history section that you personally conducted the HPI and reviewed all other history elements, and INITIAL it

Problem #2Unclear Review of History

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If the history is brought forward and you make and initial a “reviewed” statement, your level of history is credited as the same as the history you reviewed (IF it was medically necessary!)

The DOCTOR, not the staff must initial the review

EXAMPLE REVIEWED STATEMENT“I personally conducted the HPI and reviewed the patient’s history elements and made changes where appropriate. JWD 1/1/16”

This one is easy to fix

Every diagnostic test must have an associated interpretation and report

Without an interpretation and report, an auditor can deny reimbursement for the test

Here’s the rub…CPT did not bless us with directions on what should be included in an interpretation and report

Problem #3Documentation of Interpretation / Reports

What many suggestStatement of reason test was runBrief summary of resultsStatement of reliability of the dataStatement of cooperation of the patientDiagnosis associated with the test or statement of

how the results will assist in diagnosis and management of condition

Documentation of Interpretation / Reports

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CPT says that for every diagnostic test…It must be clear to the auditor from the medical

record why you performed the test-OR-

The record must include a physician “order” for the test

The first one is deadly – the second is much better!

Problem #3 subsetOrders for Diagnostic Tests

In the plan of the previous examination (that the auditor does not have!)

In the reason for visit for the current examination In the plan of the current examination or in an

order section noting the test is to be performed that day

Three Places for Orders

All OK… but suggest #1 (for your tech’s sake) AND #2 or #3 (for the auditor’s sake)

CPT / CMS require that patient encounters must contain a signature of the examining physician

Although not mandated, could be best if on every page of the examination (easy with most EHRs)

For a paper record, a signature is just that….your written signature – MUST be legible (or claim DENIED!). For that matter, if ALL your written recordings are not legible, claim denied. Can attest with signature log or printed signature (no stamps or “signature on file”).

Problem #5Medical Record Signatures

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EHR SignaturesElectronic - “Electronically signed by Joe DeLoach,

OD 9/2/13 4:30pm”Digitized – an actual reproduction of your manual

signature transferred to paperDigital – an encryption or fingerprint that binds the

doctor to the record (not ready for prime time yet!)Signature Attestation - statement that you performed

all the services (far too complex)

Vision companies, especially the big ones, have specific requirements for documenting a billable contact lens evaluation. See the next slide for what they are!

Without proper documentation, companies will take back the contact lens fitting fee

One of the companies will take back the contact lens fitting fee AND the money your patient paid out of pocket for contact lens services

Problem #6Documenting a Contact Lens Evaluation

1. History needs to include the lenses worn, how they are worn, solutions used

2. Examination needs to document the fitting characteristics of the lenses (NOTE: Simply documenting WHAT trial lenses were used is not sufficient – need to note the fit)

3. Findings should include K’s and SOR (mandate of VSP)4. The assessment needs to state how the patient is doing

with the lenses5. The plan needs to state what you are doing going

forward, even if that is no change

Documenting a Contact Lens Evaluation

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Templates are completely legal and proper – if used properly

You need to assure that the findings recorded were actually from observations performed THAT VISIT (appropriate findings can look very similar visit to visit –not your fault)

How do you do that?

Problem #7Template Mis-Use

First of all, by definition, they all are – but: Lack of “except as noted” language No signed review of history OVER or inappropriate documentation of case history

(“over”- really?) Impossible findings (best example – retinal periphery is stated

as normal but patient was not dilated) Diagnosis with no abnormal clinical findings The obvious – EVERY chart looks the same

“Suspicious” Templates

EVER HEARD OF AN “AUDIT TRAIL”?

Problem #8Listing Wrong Diagnosis(es)

There is a big difference between documentation of a medical record and what goes on your insurance form. This is not opinion, CPT directs us what to do here.

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Three Coding Tenets re: diagnoses – Per CPT

Primary DiagnosisPrimary diagnosis is the diagnosis that answers the primary reason for the visit. Should correlate with your procedure code(s) on your insurance submission.

Subsequent DiagnosisSubsequent diagnoses are those revealed during the encounter. They may or may not be included on the insurance submission but may demonstrate increased complexity of the encounter or justify medical necessity of other services.

Existing DiagnosesExisting diagnoses are those conditions the patient has or has had in the past. They SHOULD NOT be included in the insurance submission unless the physician took action on them during the encounter.

Problem #8Diagnosis(es) without findings

One of THE most common audit issuesREALLY??? Really!!!Guys and Gals – this one is simple. You must have

documentation of your assessment and you have to write it down in the examination findings.

Simple….don’t be careless!

Problem #9 – Grandaddy of allAttempted documentation of unnecessary care

So how does this work… First audit (nurse or lay person) – simply deniedPeer appeal (must be optometrist) – you must justify every

examination and test performed based onMedical necessityPreferred practice patternsStandards of careProve not “worthless” (remember how CMS defines that)

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Whew…….

Let’s take some questions

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1

Joe DeLoach, OD, FAAOClinical Professor, UHCO

CEO, Optometric Business Solutions

I have no financial interest in any product, procedure, or technology mentioned in this

presentation. I speak routinely for various companies including Alcon, Zeiss-Meditec, &

OPTOS. I manage Optometric Business Solutions, a practice management,

consulting company, but have no financial interest in the company. My opinions do not necessarily reflect those of the University of

Houston College of Optometry.

OPTION ONELet’s have the four thousandth lecture you’ve heard

on dry eyes and/or allergic conjunctivitis and I’ll try to convince you my favorite magic drop is better than the rest, blah, blah.....

-or-OPTION TWOLet’s look at some things that really happen

that are often misdiagnosed and/or mismanaged

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1. CIN (conjunctival intraepithelial neoplasm)2. RCE (recurrent corneal erosion)3. AIC (adult inclusion conjunctivitis)4. HSK (herpes simplex keratitis5. AOC (autoimmune ocular complications6. “IARIIIYC” (it ain’t rare if it’s in your chair)

NUMBER ONEConjunctival Intraepithelial

Neoplasm (CIN)

• Uncommon? Actually THE most common conjunctival malignancy in the United States

• Histologically similar to cervical intraepithelial neoplasm…also called CIN

• 90+% Unilateral• Textbook says fair skinned individuals – but not in

my experience!• More common >60 y/o. Suspect immuno-

compromise in youngsters (maybe <30ish)• The problem? Precursor to squamous cell

carcinoma – 100% of time

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Etiology1. Known: UV induced dysplasia in already

“at risk” individuals/tissue (lighter skinned; high exposure to UV; family or personal history of skin cancers, or….)

2. Recently Proposed: Dysplasia secondary to tissue compromise from viral infection –esp. Herpes (“at risk”)

The Presentation - Four Classic Signs1. Raised, gelatinous mass on conjunctiva (often FIRST)2. Suspicious vascularization (always)3. Leukoplakia or plaque – typically limbal (initial area of

cellular dysplasia – least common EARLY sign)4. Pagetoid or frosted spread onto cornea (usually LATE)

Diagnostic Hints1. CIN moves freely on palpation – when it stops moving

the patient is in trouble!2. Stains with Rose Bengal

This image cannot currently be displayed.

Classic mid-advanced appearance

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Classics(doesn’t get any

better than these)

Slightly less classic

Watch that vasculature

This was NOT a corneal infiltrate

Everything is a snapshot in time!

Let’s talk about this important concept

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REALLY watch those blood vessels!

If you were photo and monitoring, it is past time to stop! This is squamous cell!


Time ran out – a while ago!This is advanced squamous cell

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CIN – Treatment Options• If only suspect, photo and monitor…watch every

4-6 months (very unpredictable growth rate)• Surgical excision with intraoperative 5-FU and

mitomycin-C . Need good hands - recurrence >90% if incomplete excision

• Topical mitomycin-C for a month• VERY effective treatment….topical INF_2b

(compounded interferon). Intrinsic antiviral and antiproliferation properties. Highly effective, almost no side effects, even though mechanism not well understood! Problem - $$$$

NUMBER TWORecurrent

Corneal Erosion

Without a doubt, one of the most misdiagnosed and mismanaged anterior segment problems!

Often can diagnose by history alone• Prior insult (often “organic”) – weeks to years• AM pain – intense, sharp, over pretty quick• Typical increasing incidence & severity• Intolerance to NON-contact lens wear• History of a “scratch” that has been a

problem ever since• History of prior care for similar symptoms

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Without a doubt, one of the most misdiagnosed and mismanaged anterior segment problems!

Confirm by clinical signs Visible basement membrane defects

(often difficult – look carefully for characteristic negative staining with a “suspect eye”)

Staining patterns vary – if inactive, often negative staining; if active, can show positive and/or negative staining

What causes RCE?



Surgery: “Trauma by appointment”


In my opinion, THE most common cause – improper wound management

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Travesty of care…This image cannot currently be displayed.

16 y/o CM. Initial injury was a fingernail scratch during basketball game. Upon presentation to me, eye had been patched for five days by OMD. Note complete blurring of iris detail – due to +3-4 cells in A/C

Classic – pressure patched by one doctor for three days, BCL by another for two weeks – but wound never cleaned.

This is technically classified as a non-healing epithelial defect at this point

Loose epithelial tags“Rolled” epithelial edgesDebris on basement membraneEdema

You wouldn’t treat an injury to your arm this way!

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NOTE: Total fibrotic cover over exposed BM. Patient was ASYMPTOMATIC!


What Doesn’t Work• Hypertonics (do NOT fix the problem – opinion, a TOTAL waste of

time if used alone – only delay the inevitable)• Debridement (very rarely fixes problem, only resets time for next

recurrence)• Anterior stromal puncture (barbaric and only scars over the

problem, despite claims)What Can Work• LONG DURATION bandage CL + tetracycline +/- topical steroids• Superficial keratectomy• PTK

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My Recipe for Medical Treatment• If applicable (usually is), clean the wound • CIBA NightDay bandage lens – replace no more than

every two weeks. Leave on minimum of 4-6 weeks past epithelial cover (consider longer!!)

• If contact lens patient – Moxeza, etc. tid 48 hours then qd; if not – Polytrim qd-bid (as long as BCL on eye)

• Doxycycline or minocycline – 50mg qd-bid for at least 30 days

• Non-preserved artificial tears• Steroids?

If treated aggressively, 50-75% cure rate!

RCE Treatment Other Possibles

• Amnionic membraneo Simple procedure – not much more complicated than a BCLo Literature promotes positive results; companies report

SIGNIFICANT results – I’m running 50:50o VERY costly – always pre-certify, esp. major medicals

• Autologous serum therapyo A bit complicated – but positive resultso Must have relationship with laboratory experienced in this or

involve PCP

A Jackhammer

Vs.

A Dremel Tool

My Recipe for Surgical TreatmentSuperficial Keratectomy

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Topical Anesthesia for the patient

(tetracaine best – or gel preparation)

“Calm hands” medicine for the Doctor

“Attempt” to identify area of BM defect

Use surgical spear to define limits of defective epithelial attachment – be ready for a surprise!

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May end up here –or worse

Diamond burr to remove defective

epithelium and create

contoured healing edge

DON’T WIMP OUT HERE!!!

Heals poorly in 3-7 days

Heals perfectly in 1-2 days

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Must keep rotation of burr moving from edge to center of defective epithelium to achieve a

smooth transition edge

Always cut “into” the

edge of the wound

Just think about what you are trying to achieve

FINAL STEP –MOST IMPORTANT

Polish the basement membrane

If performed correctly, treatment is near 100%

effective

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Bandage contact lens1-2 months (prefer NightDay)

Prophylactic topical antibiotic (prefer Polytrim)Pain control – pain will increase with increase

chronicity and size of defective area. Typically requires narcotic pain meds (don’t ask your patient to be a tough guy on this one!)!

Progress every few days till epithelial cover. Then don’t be too quick to remove the BCL (rarely less than a month)

Final Points• Both surgical options best

performed on a stabilized, quiet eye

• PTK is a fine option, especially if there is also some myopia standing in the way of perfect vision!!

NUMBER THREEAdult Inclusion Conjunctivitis

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Possibly Staggering EpidemiologyChlamydia is the most common STD in US

• Effects 3.9% of all females 14-19 y/o (Gottlieb – Pediatrics 12/2009)

• 1.5 million new cases per year in same group (14-19 y/o). Overall, 3 million new cases per year in US.

• VERY likely WAY off (est. 250% off )due to lack of reporting and misdiagnosis

• 2014, 22 cases at CSEC (2800 new encounters – 0.7% in a population with average age 58)

THE most common chronic, follicular conjunctivitis

Characteristics• C.trachomatis, serotypes D-K and L1-L3 • CHARACTERISTIC initial significant mucopurulent (but

follicular) conjunctivitis followed by less significant recurrences. RARE Dx on initial presentation.

• Unilateral common, some asymmetric bilateral cases• Superior conj staining +/- corneal pannus• CHARACTERISTIC non-tender +PAN• CHARACTERISTIC follicles inferior AND superior (superior

is DIAGNOSTIC!)• < 50% have genital symptoms (esp. males)

Key Diagnostic Hints• Recurrent history• Numerous symptomatically

successful prior treatments, but…• Unilateral presentation (significant

asymmetry with other eye involved sometimes)

• Inferior PLUS SUPERIOR follicles• Non-tender PAN

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20 y/o F presents for a “refraction so she can get a pair of glasses because my CLs hurt”. One year history of several “eye infections” treated with multiple eye drops. First time was really bad but “responded to drops” – but keeps coming back every few months. Saw a doctor two weeks ago who diagnosed a “rejection to her contact lenses”. Was prescribed Lotemax and Zaditor but she says it really isn’t getting much better!!

These critters are

DIAGNOSTIC

THIS is a huge

problem

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• Treatment of choice – oral azithromycin, at least 1gram single dose (or Z-pac!)

• Alternates: doxycycline 100mg BID or erythromycin 500mg TID, either med for three weeks

• Adjunctive topical therapy debated (steroids mask the disease but totally OK for use as long as you have the real problem covered!)

• Refer to urologist / OB-GYN (still valid concept?)

Treatment

Time to be brave doctor now!

NUMBERFOUR

Herpes Simplex Keratitis

Basic Stuff• Herpes is the most common virus found in the

human body • Almost ALWAYS a secondary activation of prior

infection (even if congenital) – stress, fever, trauma, UV exposure

• Multiple tissue specific serotypes…or used to be!!• 500,000 new or recurrent cases in US annually• Likely WAY more common than thought as many

and MAYBE MOST initial epithelial presentations are self-limiting (rarely taught truth)

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HSK ‐ “The Great Masquerader”• Classic symptoms of pain, tearing, photophobia,

blurred VA (depending), variable corneal hypothesia –OFTEN followed by typical to atypical dendritic corneal exophytic lesions with terminal end bulbs

• Severity of symptoms HIGHLY variable…early in process, symptoms often out of line with clinical signs (more OR less severe)

• Typically unilateral• Common history of similar presentation• Epithelial vs. Stromal

Where it all starts!This image cannot currently be displayed.

Typical Presentation

BUT…

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And stromal…yuk

Treatment• Often one of the more debated

concepts in anterior segment disease…but really shouldn’t be

• Despite many current “expert” opinions, not all the answers can be found in the HEDS Study (Herpes Eye Disease Study) –It is almost 20 years old and conducted during the infancy of oral anti-virals!

HEDS Summary Epithelial disease does not always make future recurrences

more likely, but stromal disease definitely does (8-10X more likely recurrence) – likely still true

Stromal disease can occur in the absence of previous epithelial lesions – likely still true

And oral antivirals….debated for sure* 45% decrease in the rate of recurrence for all forms of ocular complications BUT ONLY WITH PRIOR STROMAL DISEASE, NOT EPITHELIAL * Oral Acyclovir did not improve the ultimate outcomes in cases of epithelial or stromal keratitis* Treatment of patients with epithelial dendrites with oral Acyclovir does not reduce the rate of stromal disease or iritis.

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And steroids?? Are they REALLY the

ultimate contraindication as taught?

• Steroids were very effective, if not essential in managing stromal infections and did not increase the rate of recurrence

• Not a part of HEDS, but many publications advocate for steroid use in EPITHELIAL disease used in conjunction with antiviral treatment

NOTE: There are many myths associated with steroid use!

Current recommendationsEPITHELIAL• Viroptic (trifuluridine) q2h, taper to qid in a week, tid for

additional week once dendrites resolved…or Zirgan(ganciclovir) q3h then tid for a week once dendrites resolved (MUCH better choice!!! And why??)

• Consider cycloplegia• Consider steroids• Consider orals - not usually in my opinion -

unless chronic recurrence or stromal• Remember…anti-virals are pretty toxic!

Current recommendations

STROMAL• Topical steroids – dosage debated from

aggressive use (q1-2h) to “lowest dose possible to control inflammation, usually q1-2h” (geez)

• Consider topical antiviral prophylaxis (Zirgan qd to bid great choice, but…)

• Consider orals – definitely if history of recurrence (often is) – acyclovir 400mg x 10 days

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And prophylaxis?Acyclovir 400mg BIDBut….does it really work

Acyclovir Prevention Trial (APT) ResultsDuring the 12 months of the study:• Epithelial recurrence decreased from 11% to 9%• Stromal recurrence decreased from 13% to 8%

Side effects of anti-virals: significant GI disturbance, kidney damange, agitation, confusion, anemia, muscle pain, seizures….

Number Five:

Ocular complications from autoimmune

diseases

Why Autoimmune Disease?

• There are >65 forms of auto-immune diseases as recognized by the American Autoimmune Related Disease Association (AARDA)

• Many of the diseases themselves have ophthalmic manifestations

• Some of the disease treatments have ophthalmic manifestations

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Main/Common Ophthalmic

Manifestations ‐ Review • Uveitis / Iritis / Cyclitis (RA, AS, Bechets, IBS, Wegeners)

• Scleritis / Episcleritis (RA, Lupus)

• Keratoconjuntivitis Sicca (KCS) (ALL OF THEM!)

• Diplopia (MS)

• Retinal vascular changes (APAS)

• Optic neuropathy (MS, Lupus)

Uveitis

UveitisWHAT IS IT? • Uveitis is a breakdown in the blood-aqueous

barrier – inflammation of the iris, ciliary body and/or choroid

WHAT CAUSES IT?• Other than trauma & idiopathic, autoimmune

disorders are the number one cause of all uveitis

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Most Common – Rheumatoid Disease• Systemic arthritis in multiple locations – joints, skin,

kidney, heart• Young female (10:1 over males)• Classic – joint symptoms worse in the morning but

ocular symptoms (esp. dry eye) worse in evening• ~25% of RA pts have ocular manifestation - most

commonly dry eye (KCS), episcleritis, scleritis, uveitis• Necrotizing scleritis without inflammation is

Scleromalacia perforans (this and scleritis very rare!)

Uveitis What Does It Look Like

• Pain, hyperemia, photophobia• Reduced vision, usually because of a

steamy cornea• Cells/Flare/Hypopyon in the anterior

chamber• IOP often low in acute cases (decreased

aqueous production) – can be high in more chronic presentations

Uveitis – What Do We Do About It• Reduce inflammation - topical steroid (Pred Forte,

OmniPred, Durezol) QH with SLOW taperProblems with Durezol rebound?

• Cycloplegic BID – to reduce synechiae, not pain• If IOP significantly elevated, appropriate IOP-

lowering agent (beta blocker, CAI – usually not a PGA because of inflammation). IOP will go down if inflammation goes down

• If systemic etiology suspected, make appropriate referral

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Uveitis

25 y/o CM presents with moderate pain and light sensitivity increasing over three days. He states this has happened 3-4 times in the past two years and was diagnosed as “pink eye” and given drops. His ocular and medical history and presentation are otherwise unremarkable. On direct questioning, he did report he had lower back pain he associated with his triathlon training over the past five years.

Uveitis

TREATMENT

• Pred Forte or Omnipred 1% QH until RTC in 48 hours; Homatropine 5% BID until RTC (Durezol?)

• Refer to internal medicine specialist with report; specify need for autoimmune panel with emphasis on back x-ray and HLA-B27

Anterior non-granulomatous uveitis (iritis)

Scleritis / Epicleritis

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Scleritis / EpiscleritisWHAT IS IT • Inflammation of the sclera or overlying episclera –

predominantly collagen tissue• Episcleritis common – scleritis VERY RARE• Most important issue is to differentiate episcleritis

from scleritisWHAT CAUSES IT• Predominantly idiopathic• Otherwise most common etiologies are RA, IBS,

AS, and LE

Scleritis / Episcleritis – What Does It Look Like

Scleritis Episcleritis

Episcleritis Scleritis• Scleritis = PAIN - a deep,

dull, penetrating “boring” ache

• Onset chronic• Typically bilateral

• Diffuse injection does not blanch with 2.5% phenylepherine

• Nodules common• Potential cause of

permanent damage

• Presents with mild “ache”, irritation or simply c/o appearance

• Onset acute typically • Typically unilateral• Sectoral injection that

blanches with 2.5% phenylepherine

• Nodules uncommon• Typically self-limiting,

BUT…

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Scleritis / Episcleritis

What Do We Do About It• Episcleritis – artificial tears; mild to strong topical

steroid depending on severity - patient• For scleritis, think ORAL (NO topicals)

Mild – Ibuprofen 600mg TID for 2 weeksModerate – Indomethacin 25mg TID or steroid 40-100mg QD with taperSevere – IV steroids; methotrexate; immunosuppresants (REFER)

• Systemic work up for any scleritis or recurrent episcleritis

Doesn’t get any

more common than

Episcleritis

52 y/o CF presents with a recurrent red eye. She has no discomfort but is concerned that the eye keeps getting red. Ocular history and exam are unremarkable. Medical is stated unremarkable although she reports taking 6-8 extra strength Tylenol a day for what she thinks is arthritis

Case 2 ‐ Episcleritis

TREATMENT• Rx FML 0.1% (or your choice) QID for two weeks

and RTC• Vasoconstrictors?• Refer patient to PCP for evaluation and treatment

of probable rheumatoid disease

Chronic episcleritislikely secondary to rheumatoid arthritis

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One unicorn to remember…

Anti-phospholipid antibody syndrome

APAS

APASWHAT IS IT • Systemic blood clotting disorder• Not very common• KEY – bilateral venous tortuosity in typically asymptomatic

young Hispanic female• Very important to identify – typically terminal disease if not

treatedWHAT CAUSES IT• Predominantly idiopathic• Otherwise most common associated autoimmune disorders

- RA, LE

APAS ‐What Do We Do About It

• No specific ocular treatment• Refer to endocrinologist for systemic work up

and treatment of systemic disorder typically in conjunction with vascular specialist. Try to bypass the PCP here!

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And dry eyes from autoimmune?

• Remember? We’re not talking about dry eyes

BUT, one point…• Treating the systemic disease often has

little to no impact on the ocular presentation

Bottom Line?• Patients with chronic uveitis should be tested

for autoimmune disease• Patients with retinal vasculature changes (and

previously ruled-out cardiovascular disease) should be tested for autoimmune disease

• Patients with acute optic neuritis should be tested for autoimmune disease

• Do not forget autoimmune involvement in dry eyes and diplopia when other causes have been ruled out

“I suspect autoimmune disease….Now what?”

• Work closely with patient’s PCP to direct appropriate serology, radiology and imaging studies

• Good idea to use pre-printed Rx sheets with tests ordered? Definitely – do not assume the PCP knows anything about this or what to order. Be a team!

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“I suspect autoimmune, now what?”

DISEASE TEST

Ankylosing spondylitis Spine x‐ray; HLA‐B27

Rheumatoid arthritis RhF, x‐ray

Reactive arthritis HLA‐B27; ESR

Juvenile idiopathic arthritis HLA‐B27; ESR; RhF; x‐ray

Bechet’s disease None – based on signs

Irritable bowel syndrome Endoscopy

Sarcoid Chest xray; ACE

Lupus ANA; urinalysis; x‐ray

Sjogrens Biopsy

Anterior ischemic optic neuropathy ESR; CRP

Wegeners Granulomytosis X‐ray; ANcA; biopsy

Multiple sclerosis MRI (often multiple)

You often know more about this

than most PCPs!• Send reports to the PCP• Work with the PCP in a team approach• Recognize that you are a primary care

health practitioner doing a health exam• Take charge and let your patients, your staff

and the PCP recognize that you are a physician

NUMBER FOURPigs do fly!

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• Surgical misadventures• Traumatic misadventures• Contact lens misadventures• “Growth” misadventures• Life misadventures

Case One: Surgical Misadventures

75 y/o CF presents with a two year history of chronic discomfort and foreign body sensations. These all started after what her cataract surgeon called an “uneventful cataract surgery”.

Vision is 20/25 and most findings normal except……

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DIAGNOSISUveal prolapse after not-so-uneventful

cataract surgeryAnd of course the ultimate question – what surgeon

considered this “uneventful” and didn’t fix this to begin with?

TREATMENT• Recommended surgical repair – patient refused• Rx topical NSAID TID – patient’s discomfort

diminished and she felt she could live with the foreign body sensation.

SequalaFollowed for the next three years until she showed up on the evening news. Patient lost her life in a shoot out during an attempted robbery of her home. She took out four intruders with a .357 SW before they got her!

at 78!

Case Two: Trauma Misadventures

23 y/o CM presents with acute vision decrease and ocular pain following a handball injury to the eye two days prior. He wears extended wear SCL and reports replacing his lenses every 3-4 months. Prior to the injury his ocular and medical history were reported as unremarkable.

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DIAGNOSISTraumatic iritis with intracorneal

hemorrhage from prior CL abuse induced neovascularization

TREATMENTRx Pred Forte q2h and homatropine bid.

Thorough DFE. The rest is out of anyone’s hands.

Case Three: Contact Lens Misadventures39 y/o CM presents for a routine RGP contact

lens evaluation. His history is unremarkable except he reports 10 years ago he lost a contact lens. He has reported mild irritation under his lid (can show you exactly where) ever since but three doctors have told him everything is fine – “you can’t lose a CL behind your eye!”

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Guess we don’t need to talk about diagnosis and treatment.

Take home message – listening and touching often works

better than looking!!!

Case FourGrowth Misadventures

55 year old black male presents C/O “growth” in the corners of his eyes. They have been present for long time but seem to be increasing in size. His ocular and medical history are completely unremarkable and other than the single external finding, his examination was completely unremarkable.

Right eye looks exactly the same!

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DIAGNOSISDermolipoma

TREATMENTFor the most part, unfortunately nothing.

Surgical removal typically requires extensive tissue removal resulting in scarring, scleral thinning and significant secondary complications.

Case Four:

Life Misadventures46 y/o AF presents for routine examination. She

reports decreased near VA but no remarkable ocular or medical history. She had an eye examination six months ago and was told everything was fine but she needed bifocals and she couldn’t afford them at the time.

20/20 distance VA OU and normal presentation, except……


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The sad definitive

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DIAGNOSISCiliary body melanomaIncidence 1:2,230,000

TREATMENTEnucleation90% mortality at one year

CASE FOUR SEQUELAEB-scan was taken almost four years ago. Eye was

enucleated. December 2014 no systemic malignancy detected. Optometrists DO save lives!

My Last Misadventure ‐kinda

68 y/o HF presents – extern comes and gets me to help remove a conjunctival foreign body. On the way down the stairs I am told the lady has cataracts but otherwise no problems. The lady was only mildly symptomatic but the extern for sure thought the piece of plastic should be removed. HINT (and excuse): We are two hours behind schedule already!

Wish I had a picture of it before I pulled on it, but this is what it looked like after I cut off the inch long

“foreign body” that zipped right out of her conjunctiva

Cut off end of extruded scleral buckle

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DIAGNOSISPrimary Diagnosis – extruded scleral buckleSecondary Diagnosis – oh sh……t

TREATMENT1. Should have pulled harder!2. Actually don’t panic – either pull the rest out (after

thorough retinal evaluation) or cut off exposed end, place patient on Mozexa QID and send off to surgeon to pull out the rest and suture closed if needed

3. Severely beat the extern who failed to report the RD repair eight years ago

AND…Remind myself

Live long and prosper!

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2016 PROFESSIONAL RESPONSIBILITY

COURSEJoeWDeLoach,OD, FAAO

CoursemasterUniversity of HoustonCollege ofOptometry

Welcome to the Professional Responsibility Coursesponsored by the University of Houston College ofOptometry. This course is a requirement for Texas licenseholders wishing to renew their license in 2017.

All fees associated with this course are devoted topermanent projects at the University that are important forthe future of our profession.

Thank you for choosing UHCO for your continuingeducation.

The development and production of the ProfessionalResponsibilityCourse is underwritten by the Harris Lee

Nussenblatt Lecture Series Endowment.This endowment was established in 1992 by the

Nussenblatt Family in memory of formerAssociateProfessor Harris Nussenblatt,OD.

The Lecture Series focuses on issues related toprofessional ethics, public health and practice

administration

The content of the ProfessionalResponsibilityCourse is at the direction oftheTexasOptometry Board. This year, theBoard requested specific issues that will fillthe entire content of the course.

Preface

First –Who Is theTOB?The Staff

Chris Kloeris Executive DirectorPattyOrtiz ExecutiveAssistantDennis Riggins InvestigationsVincent Piña LicensingDonnaMontgomery Continuing EducationMark Patterson AccountantClay Nieman IT

First –Who Is theTOB?The Board Members

Doctor Members

JohnCoble,OD (Chair)

Melvin Cleveland, OD

MarioGutierrez, OD

Ron Hopping, OD

Carey Patrick, OD

Virginia Sosa, OD

Public Members

Judith Chambers

Larry Fields

Rena Pena

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Key Points

• The Board is underfunded and under staffed – they work very hard foryou especially around license renewal time (like your last minute CE…)

•They are doing a time consuming, essential but thankless job – mightconsider thanking them for their service now and then

• It is a service – the Board member’s compensation is a whopping $36 aday plus travel expenses LESS lost revenue from the office 8+ days ayear

• They really are there to help – they are your colleagues but theirobligation is to protect the citizens of Texas by upholding the law as itis written

2016 AGENDA

1. THE Newsletter2. Rule 280.6 regarding the administration,

dispensing and charging for therapeutic contactlenses and amniotic membranes

3. Obligations regarding suspected child abuse ordomestic violence

4.Communications and Social Media

TheOptometry Board Newsletter

• First, it’s forYOU they don’t have to do it!• It is an easy way to keep up with new laws, new rules andother Board activity• It is your reminder and direction for renewing your licenseeach year

Few likely read it cover to cover. That isreally dumb…

Rule 280.6 –Amniotic Membranes

(a)Under the authority of §351.358 of theAct, a therapeuticoptometrist may administer, perform, or prescribe ophthalmicdevices, procedures, and appropriate medications administeredby topical means, to diagnose or treat visual defects, abnormalconditions, or diseases of the human vision system, including theeye and adnexa. (b) Pursuant to the limitations in subsection (a)of this title, a therapeutic optometrist may: (1) administer anamniotic membrane in a procedure that does not involvesuturing; and (2) dispense and charge for therapeutic contactlenses in accordance with §551.004 of theTexas Pharmacy Act.

Rule 280.6 –Why??

• Payer issues

• Common sense vs statute• Medical bias

So that makes the real problem with 65778…

DomesticViolence – from the law

• An optometrist who treats injuries he or she suspects werecaused by family violence is required to document thetreatment in the patient’s medical record including anexplanation of why he or she believes the injury was caused bya domestic violence situation.

• Additionally, the optometrist is required to give the patient:• Information regarding the nearest shelter• A written statement with language at least equivalent to

the language proposed inTexas Family Code 91.003

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Patient DomesticViolence FormNOTICE TO ADULT VICTIMS OF FAMILY VIOLENCE

It is a crime for any person to cause you any physical injury or harm even if that person is a member or former member of your family or household.

You may report family violence to a law enforcement officer by calling the following telephone numbers: _____________________________.

If you, your child, or any other household resident has been injured or if you feel you are going to be in danger after a law enforcement officer investigating family violence leaves your residence or at a later time, you have the right to:- Ask the local prosecutor to file a criminal complaint against the person committing

family violence; and- Apply to a court for an order to protect you. You may want to consult with a legal

aid office, a prosecuting attorney, or a private attorney. A court can enter an order that:

(1) prohibits the abuser from committing further acts of violence;(2) prohibits the abuser from threatening, harassing, or contacting you at home;(3) directs the abuser to leave your household; and(4) establishes temporary custody of the children or any property.

A VIOLATION OF CERTAIN PROVISIONS OF COURT-ORDERED PROTECTION MAY BE A FELONY. CALL THE FOLLOWING VIOLENCE SHELTERS OR SOCIAL ORGANIZATIONS IF YOU NEED PROTECTION: _____________________________.

DomesticViolence – Key Points

• These are not recommendations, they are the law. Failure toabide by these rules can result in action against youprofessionally (action against your license) and personally(civil action against you)

• It is a fine line – be very sure the evidence is supportiveenough to likely be more than just suspicious. Erroneousclaims of domestic violence can be damaging to youpersonally but more so to the individuals and families involved

Our big topic….

Office communicationsWhat’s hot, what’s legal what’s not

Social mediaWhat’s hot, what’s legal what’s not

Communications with PatientsWhat’s Hot•Talking to our patients in person, on the phone, throughemail, via text…it’s all important

• Laws regulating this extend far beyond HIPAA and mosthave been in place for a very long time

•With advancement in communication technology, thoselaws are now being revised and interpreted. Not keeping upcan be very costly to your reputation and your pocketbook

Communications with PatientsWhat’s Legal

Answers to issues regarding communication legalities arefor the most part found in twomajor pieces of Federallegislation• HIPAA•TelephoneConsumer ProtectionAct of 1991

What do they say about all this and what is new?

Telephone Consumer ProtectionActJuly 2015 Declaratory Ruling – First Issue

Implied Consent• Makes it clear that if a patient provides a telephone numberto a provider, use of that number for communicationsregarding health care information is IMPLIED and does notrequire patient authorization (it wasn’t always?)

• Ruling does not extend to emails; ruling is silent related touse of telephone number for text communication•Only exception is written instructions / prohibitions from thepatient to the contrary

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Telephone Consumer ProtectionActJuly 2015 Declaratory Ruling – Second Issue

IncapacitatedThird Party Rule•Clarifies that a patient has the right to designate priorcommunication consent for a provider to contact a third partyfor information in the event the patient is incapacitated

•Also grants rights to the provider to contact a third party inemergency situations if the patient is incapacitated andcannot provide consent

Telephone Consumer ProtectionActJuly 2015 Declaratory Ruling –Third Issue

End to EndUser Call Regulation• Establishes regulations regarding rights of provider tocontact a patient through communication channels for whichthe patient pays a fee and the communication could impactthat fee (and it wouldn’t when?)

• Classifies the nature of the communication as exempt or nonexempt – in other words what kinds of communications fallunder the rule and which do not


Exempt Communications

• Health care treatment information

• Appointment calls and reminders

• Pre Post operative instructions

• Rx notifications

• Lab result information

• Home health care information

Non ExemptCommunications

• Payment information

• Debt collection

• Any other financial information

• Marketing information

• Any advertising


Even exempt calls are regulated:• Phone number(s) limited to those specifically provided by the patient• Communications must include name of the provider and contact information for

the provider• Must be related only to the specific health care information of concern – cannot

include anymarketing or advertising information• Voice messages must be limited to oneminute or less and text messages to 160

characters or less• Communications are limited to one per day or three per week• Communicationmust include clear instructions as to how the patient can opt out

of future communications

Telephone Consumer ProtectionActJuly 2015 Declaratory Ruling – Summary

Communications (phone and text) for health care purposes are generally fine and havesome implied consent. Implied becomes suspect when:

•The communication becomes a text message

•The communication does not relate directly to the healthcare of the patient

•The communication contains any marketing or advertising

SOLUTION / RECOMMENDATION1. Place in your NPP a statement that you utilize the phone numbers provided to you

by the patient to communicate with them regarding their healthcare needs

2. For all other phone, text and email considerations the best choice is to have aseparate authorization from the patient

HIPAA Privacy & Security ClarificationsMeansWhat?

45 CFR164 522-530

All covered entities and business associates are required by law toimplement measures that “guard against unauthorized access to PHIthat is being transmitted over an electronic communications network”.

Communications can be made three ways:1. To the patient2. From the patient3. To anyone except the patient

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HIPAA Privacy and Security ClarificationsCommunications TO the Patient

“The Security Rule does not expressly prohibit the use of email tocommunicate with a patient. However, the standards requireprocedures to restrict access, protect the integrity of and guardagainst unauthorized access to PHI.”

What are “certain procedures”? Finally defined – “reasonableprecautions… equivalent to encryption (my emphasis)”

www.hhs.gov/ocr/privacy/hipaa/faq/securityrule

HIPAA Privacy and Security ClarificationsCommunications TO the Patient Summary

If you elect to communicate with your patient via email, you have two choices:

Secure theTransmission• Not sure what is “equivalent to encryption” so suggest all communications are

encrypted. HHS suggests email communication be limited to only secure patient portalsystems.

www.healthit.gov/providers professionals/guide privacy and security electronic health information

Or“Warn” the Patient• Required to inform the patient the communicationmay not be secure and the potential

consequences of that• Patient must confirm they understand the risks and wish to continue. Does not state

HOW they confirm this but anything less than written authorization would be foolish.

HIPAA Privacy and Security ClarificationsCommunications FROM the Patient

• The HIPAA Privacy and Security Rules do NOT applyto communications FROM the patient. But as soonas the provider receives the email, the informationnowmust be protected by the provider.

• Any communication BACK to the patient from theirinitial response, refer back to previous two slides

HIPAA Privacy and Security ClarificationsCommunications toAnyone EXCEPT the Patient• No stated exception to the encryption criteria and no expressed

authority for the patient to “waive” these security measures• Specifically includes text communication• Warns that providers should check with their respective text

communications company to see if they store communications,which is stated as a risk to consider

SUMMARYCommunications toANYONE except the patient, only use secured /encrypted text systems, secured / encrypted email systems with strongrecommendation for use of secure patient portal

Social Media What’s hot?

EVERYTHING!!!Unfortunately resulting in one of the largestareas of problems with patient communication,privacy of patient PHI and human resourceissues

Social Media What’s hot?

TexasWorkforce Commission quotes re: Social Media

“Fools names and fools faces often appear in publicplaces”“Although social media regulation and technologyhas improved dramatically, there has been nocorresponding upswing in common sense or decencyin society”

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Social MediaThe Four Major Legal Challenges

1. Data protection and privacyHIPAA is real and the privacy and security rules apply nomatter where information is posted

2. Employee rightsEmployees have a legal “right to know” employer policiesregarding social media and those policies cannot violatetheir protection under the National Labor Relations Boardand the 4th Amendment

Social MediaThe Four Major Legal Challenges

3. Disclosures and third party endorsementsYour employees are a legal extension of yourpractice – what they say, endorse or “like” may beproblematic

4. Governance and oversightYou have a legal obligation to monitor your businessand enforce your policies

Social MediaWhat’s Legal andWhat’s NotAll InOne

Six Social Media Situations for Health Care Practitioners• Communications with patients on social media

• Communications on blogs / websites

• Using social media for background checks, investigations of current or potentialemployees

• Employee communication on social media during business hours (“on dutyposting”)

• Employee communications on social media outside the business (“off dutyposting”)

• Employer liability for employee postings on social media

Social MediaCommunications with Patients

• Let’s start with this is, in general, not a great idea unless:

•Patient initiates the communication•Communication is generic to patient base•Communication involves marketing, advertising or generalhealth information that is also generic to the patient base

•And end with there is NEVER justification or rationale forposting any PHI on social media, even with attempted patientauthorization (can a patient “waive” their HIPAA rights?)

Social MediaCommunications on Blogs /Websites

• Obvious examples –ODWire,ODs on Facebook, etc

•What youCANNOT do without patient authorization Post anythingthat could POTENTIALLY identify the patient•The obvious – names, patient numbers, SS#, DL#, address,occupation, too much history information – and the list goes on andon. HIPAA describes a problem as “any combination of informationthat could potentially identify”

•Evidently not so obvious – identifying pictures. Definitely full orpartial facial photos but could also include any mark, irregularity orpathology that could identify the patient

Social MediaCommunications on Blogs /Websites

•This issue is generally scoffed at by blog participants. Therehave already been privacy violations on this. The CaliforniaSupremeCourt has ruled that the simple “act of posting” is aviolation even if human eyes never see the post.

•The argument of “a private blog” doesn’t hold water. Nothingon the internet is private, forever!

•The question of patient authorization is still up for grabs. It islikely a good protection but not the safest action. Safestaction is do not post anything that could even POTENTIALLYidentify a patient.

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Social MediaUsing social media to “check up on them”• This may include n0n private background checks; n0n private creditchecks; evaluating them based on Facebook page comments, likes,photos; evaluating them based onTwitter postings

• This is aVERY bad idea – because:•The information is often incorrect and not verifiable•Employers can be held liable for any decision regarding a new orexisting employee based on this information, even if the informationwas posted incorrectly by the employee or applicant

Repeat – bad idea. Don’t do it!

Social MediaEmployee on duty vs off duty communication

DEFINE:

ONDUTY communication – posting through the internet duringtime the employee is “on the clock”. The posting can be performedusing the employer’s equipment or the employee’s equipment – andthis does make a difference!

OFF DUTY communication – posting through the internet duringtime the employee is NOT “on the clock”

Social MediaEmployee on duty vs off duty communication

TheMost Common Problems

•Inefficient use of work time•Harassment (other employees or even patients)•Endorsements•Pornography

Social MediaEmployee on duty communication

Employers have every right to monitor employee activity on theinternet when such communications are:

• Made during the hours they are working for you

• Made on equipment you own or manage

•Work related – and to some degree when they are not workrelated

Social MediaEmployee on duty communication

BECAREFUL!Monitoring activities must be:• Legal in your state (legal inTexas)• Based on written office policies• Uniformly applied to all employees•Authorized by the employee – not a legal requirement inTexas but a very good idea• Based on some rational reason – surreptitious monitoring isdefinitely illegal

Social MediaEmployee off duty communication

This one is far trickier!

The National Relations Labor Board allows employers tomonitor off duty employee postings as long as the activitymight directly effect:

• Fellow co workers

•The employer’s business

•The employer’s patients, customers or other clients

• Employer’s “trade secrets” – poorly defined

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Social MediaEmployee off duty communication

The problem – poor clarity:

•The biggie – NLRB states employee’s 4th amendment rightsmust be protected. Again, how far does that go?

•“Directly effects” poorly defined – always remember laborlaws are designed to help the employee, not you

•Employees have to right to post anything related to the“conditions of their employment” – also loosely defined butdefinitely includes working conditions, compensation, hours,benefits, demeanor of the employer. And there is significantleniency regarding the complete “accuracy” of the post!

How Far CanAn EmployeeGo?Hold on to your hats…

You finish a somewhat negative annual review that does not result in apay increase for your employee. The employee is very upset and posts onFacebook:

“ABCCompany is is horrible place to work. Mr. ABC is a cheap, fatso pieceof s#*%! who doesn’t care about anything but his pocketbook”

NLRB can and likely would declare the post is allowable as theemployee’s profanity and derogatory comments about the employerweremade related to their “working conditions” and made during anemotional outburst that was the result of their disappointing review.

Texas chimes in here…Texas Penal Code 33.07

• Employers may take action against an employee for conduct that hasthe effect of damaging the company business (poor clarity and in manycases will conflict with rights granted to employee by Federal NLRB)

• It is illegal to use a false identity to create or post on a website wherethe post has the intent to harm, defraud or threaten (3rd DegreeFelony)

• It is illegal to post a communication posted by another person withouttheir consent where the intent of “carrying forward” the post is toharm, defraud or threaten (Class AMisdemeanor)

Social Media SummaryEmployee on and off duty communication

Monitoring for ANY reason in ANY situationcan be tricky!

NLRB states employees have a right to“reasonable protection of their privacy” – again,poorly defined. Likely to be defined in court if youwant to contribute to that process.

Social MediaEmployer Liability for EmployeeActions

• Without question…regarding protection of patient privacy – HIPAA holdsYOU liable for the actions of your staff unless you have followed HIPAAprivacy and security regulations

• Regarding protection of your clients and business associates, the employerhas liability for the postings of an employee that are damaging if the postingis deemed to be an endorsement or degrading action “approved by theemployer”*•Back to tricky again – poorly defined, potential infringement of 4th

amendment rights•Are we really going to take it this far? Likely to also be determined incourts

* SEC Release No. 34-58288

Social MediaEmployer Liability for EmployeeActions

How far are they going to take it?

The SEC Release encourages employers to have a policythat any “endorsement” by an employee should includea disclosure statement clarifying the endorsement like“this does not necessarily reflect the opinion of myemployer ABC Eyes”. But your choice…

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And life is just not fair sometimes!

All these “protections” do not flow both ways

•The Communications Decency Act of 1996 rules that youmay not claim damages for a network hosting site or socialmedia site for not monitoring disparaging comments madeby an employee (essentially these companies are immunefrom actions resulting from communications by 3rd party)

•Courts have ruled that employers may be held liable for theactions of their employees on social media even when suchactions are performed “off duty”

Social Media – Most Important

•At a minimum, employers should include a social mediapolicy in their employee handbook. Contents are left todiscretion of the employer based on the individualnature of the business.•Themain policy should be “Your job comes first”•Like other HR policies, you must oversee your businessand apply your policies in a fair and consistent mannerfor all employees

Social Media – Recommended Policies

Company postings should never contain:

• Confidential business information (usually financial)

• Discriminatory, defamatory, disrespectful or derogatory statementsabout other employees, patients or any client of the practice

• Any illegal, sexual or unprofessional information

• Comments of a personal or emotional nature such as politics, religionand the like

• False, unconfirmed or misleading information


Without approval, company postings should not contain:

• Endorsements of or references to products or services

• Material or information not approved by the employer

• Material copied from another source

• Information not related to the operation and purpose of the business


Without approval, personal postings should not contain:

• Endorsements of products or services except personal opinion –disclaimers recommended

• Confidential business information (usually financial)

• Discriminatory, defamatory, disrespectful or derogatory statementsabout other employees, patients or any client of the practice

• Items that could be damaging to the employer’s business

You can find many examples of socialmedia policies on line or as part of ahuman resource managementproduct from a compliance company.Customize to fit your style and needs.

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Bottom Line for Safety

• Be aware of the law – esp HIPAA•Have concrete, fair andreasonable policies in your officeregarding social media• KEEP EMPLOYEES HAPPY

ThankYouHave aGreat 2016

[email protected]

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