Kevin J. Corcoran, COE, CPC, FNAO and,
Ryan D. Alfonso, MPH
Managing Editor
Measuring the biomechanical properties of
the cornea with Reichert’s Ocular Response
Analyzer™ (ORA) enables practitioners
and researchers to quantify various corneal
conditions. Corneal hysteresis testing with
the ORA is useful in identifying abnormal corneal conditions,
evaluating IOP measurements and assessing the potential for
complications following corneal refractive surgery. Low corneal
hysteresis (CH) demonstrates that the cornea is less capable
of absorbing (damping) the energy of the air pulse. Clinical
studies suggest that a low CH measurement may indicate ocular
abnormalities or corneas at risk for disease.
Hysteresis is defined as the lagging of an effect behind its cause,
as when some neurons do not return to their basal conditions
from a stimulated condition immediately after removal of
the stimulus. Hysteresis is a property of systems that do not
instantly respond to forces applied to them, but react slowly, or
do not return completely to their original state: that is, systems
whose states depend on their immediate history.
Figure 1. Corneal hysteresis is the difference between the inward and outward applanation pressures.
One of the foremost experts on the clinical utility of the ORA
is Mitsugu Shimmyo, M.D. (New York, NY). Dr. Shimmyo
has been using the ORA in clinical studies, and in practice,
since the first prototype units were implemented in 2003.
He has presented his findings at the American Academy of Ophthalmology, the World Ophthalmology Congress, and numerous other meetings world-wide.
“There are no other methods that provide the information
ORA does. This is the only instrument to measure IOP
corrected for corneal effects (viscoelasticity of the cornea)
clinically.”
- Mitsugu Shimmyo, M.D.
The ORA has
been shown to be
of great benefit
in detecting
low or normal
tension glaucoma,
to resolve the
diagnosis of
glaucoma where it is suspected, and in the management of ocular
hypertension patients. In addition, other research shows that
incorporating the ORA in preop work-up of refractive surgery
patients may reduce the risk of post-LASIK ectasia by allowing
you to detect those at increased risk. Dr. Shimmyo also sees
value in measuring CH following corneal refractive surgeries,
and in the evaluation and monitoring of keratoconus patients. It
is important to mention that the ORA measurement is noncontact
and very rapid. The entire measurement process takes
only seconds.
Adapting a new instrument and technology in your practice can
sometimes be confusing. Here are a few key considerations one
needs to be mindful of with regard to reimbursement for ORA
procedures.
In addition to the printout following completion of CH testing
with the ORA, the chart should contain:
- an order for the test with medical rationale
- the date of the test
- the reliability of the test
- the test findings
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the signature of the physician
A form suitable for documenting the interpretation of CH
testing is available on the Corcoran Consulting Group website.
Category III CPT code 0181T should be used to report CH
testing.
- 0181T Corneal hysteresis determination, by air impulse
stimulation, bilateral, with interpretation and report.
This new technology code was effective July 1, 2007 and appears
in the 2008 edition of CPT. Medicare does not bundle CH
testing with other diagnostic tests performed on the same
day nor does it assign relative value units or a dollar value to
Category III CPT codes. Reimbursement is determined on a
case-by-case basis at the discretion of the payer.
Figure 2. Reichert's Ocular Response Analyzer™
“With the volume of patients I have, the ORA paid for itself in
two months. In my experience, Healthfirst, 1199, Cigna, and
Aetna have offered reimbursement. Some companies request
a reason to perform the test based on the information the test
provides. Some simply ask for a justification based on the
patient’s diagnosis. Answer all their questions, and you’ll find
that many companies will pay.”
- Mitsugu Shimmyo, M.D.
Since reimbursement is uncertain, and Medicare has no preauthorization
mechanism, ophthalmologists and optometrists
should consider asking the patient to be financially responsible
for CH testing. Prior to administering the test, obtain the
patient’s signature on an Advance Beneficiary Notice of
Noncoverage (ABN) for Medicare patients or on another
suitable waiver form for other third party payers.
How frequently a test may be performed and filed for
reimbursement is a common concern expressed by physicians.
There are no published limitations for repeated CH testing.
In general, this and all diagnostic tests are reimbursed “when medically indicated” for new symptoms, disease progression, new
findings, unreliable prior results, or a change in the treatment
plan. In general, additional testing is warranted when the
information garnered from the eye exam is insufficient to
adequately assess the patient’s disease. Clear documentation of
the reason for testing is always required.
Evaluating the biomechanical properties of the cornea
with the ORA is an application of advanced technology in
ophthalmology. It represents a new diagnostic tool which can
assist ophthalmologists and optometrists to better understand
the mechanism of corneal disease as well as other ocular
abnormalities.