Challenging cataract cases can have a ripple effect that extends beyond the OR and splashes onto a surgical facility's balance sheet. They can take longer to perform than fast-paced, routine anterior procedures and can add specialized supplies to the cases' costs. Administrators who know in advance that particular patients are going to present difficulties may be tempted to direct surgeons to treat them elsewhere. But there are reasons to take them on, and strategies for optimally managing them.

The catch: reimbursement
For surgery centers, scheduling difficult cataracts comes with an initial hard truth: Even though they consume more OR time and resources, they aren't any more profitable than routine cases.

"Despite the very real distinctions between complex and routine cataract surgery, the reimbursement amount is the same either way," says Kevin J. Corcoran, COE, CPC, FNAO, president and co-owner of the Corcoran Consulting Group, a San Bernardino, Calif., practice management firm that specializes exclusively in ophthalmology and optometry reimbursement.

The 2009 national Medicare ASC facility fee reimbursement for routine cataract surgery (CPT 66984) is $964.70. Certain anatomical factors, which are often — but not always — identified in advance based on a patient's medical history, can lead a case to be classified instead as complex cataract surgery (CPT 66982). The most common of these factors include the following:

• weak zonules, which require the use of a capsular tension device;
• mechanical dilation of the pupil, necessitated by a pre-existing condition inhibiting adequate pharmaceutical dilation;
• a dense cataract, which must be stained to permit capsulorrhexis;
• IOL haptics that must be sutured in place; and
• primary posterior capsulorrhexis performed on patients in the amblyogenic developmental stage.

Since Medicare's facility fee for complex cataracts is also $964.70, "an ASC is no better off even knowing it's going to be a difficult case," Mr. Corcoran notes. "Who does it matter to? It matters to the surgeon."

While Medicare's professional fee for routine cataract surgery is $638.74, it's 40% higher for complex cases, at $891.57. Medicare's relative value units judge the skill, time and risk demanded by a complex case to have more impact on a physician's efforts than on a facility's.

Why take on complex cases?
Given this disparity, would it make more sense to redirect challenging cataract cases to the outpatient ORs of your local hospital in order to limit your expenditures and risk exposure? Not exactly, say ophthalmic surgery consultants.

"Your relationships with hospitals and your constituent surgeons are more important than the economic impact of a single case," says Steve Sheppard, CPA, COE, managing principal for the Medical Consulting Group, a marketing, ASC development and practice consulting firm in Springfield, Mo.

"The overriding factor is typically that you're not going to inconvenience one of your staff surgeons by making him take a small number of slightly complicated cases to the hospital," he says. Even though ASCs won't see a direct financial incentive to schedule such cases, it's in their interest to accommodate their physician-owners as often as possible. Additionally, "the hospital might look askance at your sending the cost- and time-intensive cases to them." Even though they'll reap higher facility fees from the cases, it may create political difficulties with their administrators.

If a surgeon isn't an investor, but does regularly use your ORs, the reason to consider taking his difficult cataract cases becomes even more compelling. To maintain profitability, ASCs put considerable effort into recruiting surgeons to use their facility, says Mr. Corcoran, and declining select cases defeats those efforts. "You don't want to tell people that you are fussy about which cases you take. Telegraphing the wrong message can have a negative impact on your case volume."

To put things in perspective, he adds, think about prohibitive cases. You cannot accept patients who present with active tuberculosis, who will require the shuttering and Hazmat-style cleanup of an OR, or patients with acute cardiac co-morbidities who run the risk of death on the surgical table. "What's a few extra minutes for a complex cataract, in comparison?" Mr. Corcoran asks.

Scheduling a case elsewhere means more than a few extra minutes for the surgeon, taking into account transportation to and from — and possible waiting time and scheduling delays at — the hospital. As a result, he may take other cases there, too, to economize on time. "The profit margin on that (complex cataract) case may be minimal," says Mr. Sheppard, "but you're swamped by the loss of that morning's cases."

And possibly the loss of other, future business the surgeon might bring. "You give up that 1 case, and you might end up losing 50 more. It's not worth it in the long run," says Elethia Charoo, RN, BSN, MBA, an associate consultant for ASC development and operations consultant Progressive Surgical Solutions, who is based in Centerville, Ohio. "Then you won't make anywhere near the revenue you could have. You've got to look at the bigger picture."

Mr. Corcoran cites statistics that only about 6% of cataract surgeries are complex cases, and Mr. Sheppard notes that those cases generally require only minor changes to the routine procedure. As far as case costs are concerned, says Mr. Sheppard, the use of a capsular tension ring, for instance, adds about $100 or $150 to the cost of a routine cataract case ($200 to $300 for an IOL, viscoelastic, tubing set and eye tray). So surgery centers still see a profit margin in the $964.70 they're reimbursed, even if it's not as much as in the other 94% of cataracts they do.

"Very few people who look at the economic outcome of a complex cataract would turn that type of case away," he says. "In almost every case, ASCs would be well served in going ahead with them."

Scheduling and supply solutions
When it's known in advance that a cataract case will be complex and, consequently, may require more OR time, scheduling for efficiency should be the first order of business. "Complex cataracts should either be at the very beginning or the very end of the day," says Ms. Charoo.

The placement depends as much on a surgeon's preference as on the patient's condition. "Some surgeons like to do difficult cases first, while they're fresh, as opposed to later," she says, while others may choose to warm up with routine cases. Saving complex cases for last keeps unexpected occurrences from bogging down the schedule after them, and if the patient's complexity involves dilation difficulties, it offers more time for dilation drops to take effect.

This "first-or-last" scheduling also lets you stagger your nurse staffing for efficiency, says Ms. Charoo. Knowing the first case of the day will run long means that the post-op crew, and your routine cataract patients, can arrive a little later and are spared from inordinately long waits. If complex cases are scheduled last, the pre-op nurses can prepare their area for the next day, make their phone calls or even leave early while the final case is in the OR. "You're not recouping everything, but you're recouping a little bit," she says.

The supplies a surgeon needs for a complex case aren't routinely packaged on a standard cataract tray, says Mr. Sheppard, so communication between the surgeon and the ASC's scheduler regarding the nature of the case is essential in order for the scrub tech to have the necessary sterile instruments and disposables available and opened at case time.

"The surgeon knows what he's going to need and not going to need," says Ms. Charoo. "You can't really tell him, 'No, you can't have that,' and there are not a lot of items you can save on." Even though some observers propose the reprocessing of iris hooks and other ophthalmic surgical supplies to economize on case costs, she emphasizes that the general consensus is that they should be discarded after their intended single use.

Since complex cases are relatively infrequent, however, materials managers should avoid tying up cash by overstocking the necessary supplies. Ms. Charoo recommends a par level of 2 sets of each supply on hand: One to use and the other as a backup. For capsular tension rings, which come in 3 sizes, stock two of each size. This suggested level depends on case volume, of course. "If you see more than 5,000 cataract cases a year, then maybe you'll want to stock 4 sets of each," she says. "And if you find you have an onslaught of complex cases, adjust your inventory accordingly."

If a substantial percentage of your cataract patients are covered by third-party payors, it may be advantageous for you to negotiate carveouts into your contracts with those payors that will reimburse you for capsular tension rings, iris hooks, eyelid weights and other supplies used in complex cases. "We've been successful in negotiating that out with payors," says Mr. Sheppard. "It works the same way you negotiate Medicare's $50 for New Technology IOLs with third-party payors." He recommends explaining the occasional need for specialized equipment, backed up with your case data or national statistics.

Routine or complex?
A surgeon who performs a complex cataract should be sure to note that designation on the billing sheet, so as to prevent the business office from accidentally miscoding the case as a routine one, says Ms. Charoo. In a physician-owned ASC or office-based facility, where the same staff are billing for the facility and the professional fee, that error would result in lost revenues for the surgeon.

Keep in mind, however, that not every complication results in a complex case. "Just because you think it's complex doesn't mean it is," says Mr. Corcoran. When the ASC's and the physician's billers are working separately, this can create controversy, because the claims they file for the case must agree.

Mr. Sheppard notes that the CPT code book lays down the law on what is and isn't a complex cataract case, and should be able to settle the matter. "But if it really became contentious, a reimbursement consultant would be able to help," he says. "Or, if no one can determine whether it's a complex case, defer to the surgeon." There's no risk in trying, and, as noted above, the ASC won't lose either way.