Understand Ophthalmological Diagnostic Testing

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Understand Ophthalmological Diagnostic Testing
CPT manual section Special Ophthalmological
Services describes diagnostic tests that go
beyond eye exams. These tests may be reported in
addition to the general ophthalmological services
or evaluation and management services. Diagnostic
tests are usually reimbursed separately by most
payers. Documentation of diagnostic tests should
clearly mention why the physician ordered a
diagnostic test and how the test helped clinical
decision-making and management. In this blog, we
discussed ophthalmological diagnostic testing
which includes discussing the importance of
selecting diagnosis, Interpretation, and Report
(IR) and the difference between diagnostic tests
screening tests.    Every time you order and
perform an ophthalmological diagnostic test, you
must have proper medical necessity established
for it in the medical record otherwise a
third-party carrier wont pay for it. If you have
a specific reason for which you believe that a
test may be denied, then use an advance
beneficiary notice (ABN) and the appropriate
modifier accordingly.   Also, note that simply
performing the technical component of the test is
not enough nor is simply initialing the test to
show that youve looked at it. When a carrier
finds that an IR hasnt been completed, then the
entire test is deemed to be invalid this means
that youll have to return the entire payment to
the carrier, not just the amount for the
professional component of the test.
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Understand Ophthalmological Diagnostic Testing

• Selecting Diagnosis with Diagnostic Tests
• Medicares guidelines for selecting the diagnosis
  mandate the following guidelines
•  
• If the test confirms a diagnosis, then code the
  diagnosis. An example of this is a patient who is
  referred for possible cystoid macular edema.
  Fluorescein angiography is performed, and a
  diagnosis of cystoid macular edema is made.
  Therefore, code the findings. 
• If the test results do not yield a diagnosis or
  are normal, then the signs and/or symptoms that
  prompted ordering/ performing the test should be
  coded. For example, a patient is referred for
  treatment of possible cystoid macular edema,
  fluorescein angiography is performed and no
  evidence of macular edema is present. Because the
  test is normal, the claim is coded according to
  what prompted the ordering of the test, such as
  blurred vision.
• If the physician performs a test on a referred
  patient to rule out a diagnosis or with an
  uncertain diagnosis, then the diagnosis is coded
  according to the signs and/or symptoms that
  prompted ordering or performing the test.

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Understand Ophthalmological Diagnostic Testing
For example, a patient is referred to a retina
specialist by a comprehensive ophthalmologist
with a working diagnosis of cystoid macular edema
in the right eye, fluorescein angiography is
performed, and it does not confirm the presence
of macular edema. An appropriate diagnosis for
the test would be blurred vision. The most
serious harm a physician can cause a patient in
chart documentation is attaching an inaccurate or
non-existent diagnosis. That diagnosis follows
the patient for the rest of his or her life and
can irrevocably damage various aspects of their
future, such as haunting them when they try to
obtain employment or insurance coverage.    Interp
retation and Report (IR)   As the name suggests,
you must interpret the results of the
ophthalmological diagnostic test and report on
how the test affected the care plan for the
patient. Please note that the diagnostic test is
not deemed to be completed until the
interpretation and report have been finished.
Whenever there is a notation of with
interpretation and report included in a Current
Procedural Terminology (CPT) code descriptor,
Medicare requires the following
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Understand Ophthalmological Diagnostic Testing

• An Interpretation and Report containing the three
  Csclinical diagnosis, comparative data, and
  clinical managementincluded in the chart
  documentation. This should be separate from the
  examination and on a form or in an area of the
  EHR that is clearly labeled Interpretation and
  Report. Medicares rationale is that because
  physicians get paid separately for these tests,
  they must have additional separate documentation.
  The information may be, and usually is,
  duplicative of that in the Impression and/or Plan
  in the chart documentation.
• Each test billed for should have its own
  Interpretation and Report document. For example,
  fluorescein angiography and fundus photography
  must each have a separate report. All ophthalmic
  diagnostic tests listed in the CPT manual that
  include with interpretation and report in the
  description must each have one. This includes all
  tests except gonioscopy and ultrasound for
  performing IOL calculations.
• Each diagnostic test, with the exception of
  extended ophthalmoscopy and gonioscopy (both are
  considered physician services only, but only
  extended ophthalmoscopy requires an
  Interpretation and Report), has a professional
  component and a technical component. The
  technical component covers the cost of equipment,
  maintenance, and technician services, whereas the
  professional component is the Interpretation and
  Report document itself.
•  

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Understand Ophthalmological Diagnostic Testing
Without the Interpretation and Report, the
provider is not entitled to the full global fee
for the test. The global fee equals the sum of
the professional component and the technical
component.   Diagnostic Tests and Screening
Tests   While billing for optometry practice, the
billing team may get confused between
ophthalmological diagnostic tests and screening
tests. Screening is part of a wellness program to
check for diseases that may otherwise go
undetected. Screening is not required by medical
necessity its optional. Most payers along with
Medicare will not cover screening tests.   Do not
file claims for screening tests, collect your fee
directly from patients. You can use Advanced
Beneficiary Notice (for Medicare)/ Notice of
Exclusion from Health Benefits (for other
third-party payers) of non-coverage to notify the
beneficiary in advance. Any Optometry practice
has medical billing challenges as office managers
and staff are trying to perform multiple roles at
the same time. That means they cant dedicate the
proper time and energy to ensure a properly
functioning revenue cycle.  
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Understand Ophthalmological Diagnostic Testing
Medical Billers and Coders can assist you in
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