Visual field testing

Whatever the frequency, documented medical necessity is the key.

As part of your ongoing compliance plan, you perform internal chart audits. You discover that one of your ophthalmologists performs far more visual fields than the other members of the group. Occasionally, he orders three or four visual field tests in a 12-month period for some of his glaucoma patients. The Local Coverage Determination for your carrier states that “claims for visual field testing submitted at a frequency greater than is necessary for the reasonable medical management of the disease may be denied.” All of the claims were paid, but your Compliance Officer believes some were unjustified.

Is a refund required?

In this situation, the chart audits do not question whether the visual fields were done but raise doubts about the need for these tests from a medical necessity point of view. In order to address this difficult and controversial topic, we must consider the standard of care where visual fields are concerned, the payment policy and the individual circumstances of each case.

Standard of care

The American Academy of Ophthalmology’s Preferred Practice Patterns provide a useful point of reference for the standard of care. These carefully written treatises on clinically relevant topics together with the body of published scientific papers in peer-reviewed journals constitute the most objective testament on medically necessary care. While the use of visual fields as an aid in the management of glaucoma is well established, the frequency of testing is variable and depends on a number of factors including severity of glaucomatous damage (mild, moderate, severe); the stage of the disease; the rate of progression; the extent to which IOP exceeds the target pressure; the number and significance of other risk factors for damage to the optic nerve; and reliability of the test (learning effect, suspicious finding).

Consequently, recommended frequency of visual field evaluation varies considerably. In the most severe cases, the follow-up interval is 1 to 6 months, but in the mildest cases the follow-up interval is 6 to 18 months. Clearly, there is no single number of visual fields that is appropriate for a 12-month period.

Furthermore, the kind of visual field test performed may have a bearing on frequency of testing. While automatic static threshold perimetry is the preferred technique, other tests may be useful too (eg, short wavelength automated perimetry, frequency doubling perimetry, motion detection perimetry, preferential hyperacuity perimetry).

Any challenge to the medical necessity for visual fields should give the benefit of the doubt to the ophthalmologist, particularly if the reviewer is a paraprofessional or administrative staffer.

Payment policy

Medicare’s National Coverage Determination 80.9, Computer Enhanced Perimetry (Rev.1, 10-03-03), CIM 50-49 states, “Computer enhanced perimetry involves the use of a micro-computer to measure visual sensitivity at preselected locations in the visual field. It is a covered service when used in assessing visual fields in patients with glaucoma or other neuropathologic defects.”

By way of amplification, the introduction to the National Coverage Determination (NCD) manual states, “Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions.” Consequently, it is necessary to check your local Medicare carrier policy for additional information regarding covered indications, limitations and diagnoses beyond the NCD.

Not uncommonly, the Local Coverage Determination (LCD) contains language such as, “Visual field testing may be medically necessary in a glaucoma suspect or a patient with glaucoma, mild damage and good control only once a year. Field testing may be necessary in patients with moderate or advanced glaucoma and good control once a year. Field testing may be necessary in mild, moderate or advanced glaucoma and borderline control two times a year. Finally, visual field testing in patients with uncontrolled glaucoma may be necessary up to four times a year.”

As a practical matter, the limitations in the LCD provide an indication that the beneficiary could be financially responsible for testing beyond these ceilings. In such cases, an Advance Beneficiary Notice should be used before more frequent testing. Even when an Advanced Beneficiary Notice is used, Medicare might pay the claim anyway.

Chart documentation

The evidence in the medical record is a powerful indicator of the physician’s thought process and judgment about an individual patient’s disease and care. While the notations are explicit about some observations and assessments, some other physician sentiments can only be inferred. For example, poor control of IOP might be stated as such, but the reason for the poor control may be obscure or merely implied.

The essential elements of a chart notation related to visual field testing include:

An order for the test with medical rationale.
An assessment of whether the test was reliable.
The results of the test, including noteworthy findings (if any).
Implications of the test, including diagnosis (if possible).
The impact of the test results on the patient’s treatment and/or prognosis.
Physician’s signature.

The chart reviewer uses the notations in the chart to answer the tough question, “Should a claim for reimbursement be paid?” Sometimes, the physician who ordered and interpreted the test is asked to provide additional perspective, particularly if the underlying medical condition is complex or unusual (eg, multifactorial disease, pediatric case).

Some classic reasons for denial of payment based on the chart documentation include:

Visual field testing was performed based on “standing orders.”
Visual field testing was ordered by someone who is not treating the beneficiary (CFR 410.32).
Visual field testing was ordered for an indication that is not covered by the payment policy.
Visual field testing was not performed under the supervision of an individual meeting the definition of a “physician” (PM B-01-28).
There is no interpretation of the visual field.

In some cases, it is apparent that the test is worthless and should not be billed at all. This may occur when the test instrument malfunctions, the patient does not follow instructions, or the test is aborted before completion.

Conclusion

The answer to the question “Is a refund required?” depends on whether medical necessity is demonstrable, based on the chart documentation, and within the context of the NCD and LCD. Generally, reviewers give the physician the benefit of the doubt unless there is clear evidence to the contrary.