On its own, glaucoma is neither a profitable nor a popular enough surgery to make you want to add it your caseload. But when you consider how nicely a few glaucoma cases fit onto the end of a cataract schedule, glaucoma suddenly becomes desirable. Your surgeons will thank you, too. Hosting glaucoma procedures is convenient for surgeons who are already filling your ORs with high-volume cataract cases. And did we mention that Medicare ASC reimbursements are up in 2011 for 3 commonly performed procedures? Let's look at glaucoma's standard surgical treatment options and what it takes to make them work financially at your facility.

• Laser trabeculoplasty (CPT code 65855). We purchased our laser several years ago for around $65,000. That might seem like a lot to pay for a relatively low-volume procedure, but we broke even 2 years after the purchase by hosting 10 to 20 cases a month.

It was added to the list of Medicare-approved ASC procedures in 2008 at a reimbursement of $132, so you'll receive approximately $150 (actual Medicare reimbursement rates depend on your local wage-index-adjusted rates) in 2011, now that the revised ASC payment plan has been fully implemented. From commercial payors, we've negotiated payments as high as $500. Supply costs are negligible and only 1 staff nurse is required to assist the surgeon.

• Trabeculectomy (CPT code 66170). Medi-care's reimbursement for this procedure is set for approximately $945 in 2011. With per-case supply expenses at about $250, the profit potential is strong. We've negotiated reimbursements as high as $1,225 from commercial payors.
• Trabeculectomy with glaucoma drainage implants (CPT code 66180). Medicare is scheduled to pay $1,675 for an aqueous shunt procedure in 2011. Remember that the revised ASC payment plan no longer reimburses for devices, so once you factor in the cost of the implant (around $500 to $800), standard supplies that total close to $250 and a patch graft that runs $275, the profit from Medicare cases is negligible. Still, that's a more promising picture than the $950 we received for these cases just last year.

Hosting patients with commercial insurance provides more financial flexibility. Reimbursement varies across payors, and the cost of the shunt procedure can vary depending on the implant used. Some payors let you bill for the procedure and the device separately; others only let you bill the procedure as a whole. If you're negotiating with a payor that bundles costs into a single reimbursement, be sure the rate and language of the contract lets you bill enough to cover the cost of the shunt. An Ahmed valve, for example, costs $495. When these implants are involved in a case, be sure your surgeons generate accurate operative reports and your billing department knows to properly code for the additional expense.

We've been able to negotiate upwards of $2,100 for the shunt procedure (implant reimbursement included) from third-party payors, which grows the per-case profit margin. Carving out the implant costs while negotiating with third-party payors further ensures you're maximizing the procedure's profit potential. Billing for CPT code L8612, which identifies the use of a device, nets my facility $500 to $1,500 more to help cover the cost of the drainage implants.

Glaucoma's profit potential
You might realize some additional revenue from glaucoma procedures, but first focus on covering your expenses, especially the cost of aqueous shunt implants, should your surgeons choose to use them. Below is a breakdown of the reimbursements, time patients will spend in your center, supply costs and staffing needs for 3 common glaucoma procedures.

Taking the plunge
If you're already hosting cataract cases, you likely have most of the necessary equipment and instrumentation to add glaucoma. Additional purchases might include sutures that help create a watertight sclera flap, a scleral punch, pericardium patch grafts, instrumentation for performing an iridectomy and scissors designed to cut the eye's conjunctiva. The biggest adjustment you'll have to make is related to managing the lengthier, more complex procedures. Your clinical team has its cataract surgery routines down cold in order to keep a day's schedule humming around cases lasting 15 minutes or less. Glaucoma cases can last 2 to 3 times longer, meaning you should stack them at the end of a day's schedule so they don't disrupt the efficiency of your bread-and-butter cataract caseload.