Show a diagnosis-driven reason when billing for tests

Today’s imaging technologies have become indispensable diagnostic tools in cases of suspected glaucoma, cystoid macular edema and other conditions. For the most part, insurance companies recognize the importance of this testing with appropriate reimbursement, according to practitioners.

“We have no problem getting reimbursed for these technologies,” said John A. McCall Jr., OD, a Primary Care Optometry News Editorial Board member in private practice in Crockett, Texas. “This can vary from state to state, but in our practice, it is a rarity if we have any problems with reimbursement for these procedures.”

Establish medical necessity

John A. McCall Jr.

According to Dr. McCall, establishing medical necessity is key to obtaining reimbursement for the use of technologies such as GDx (Carl Zeiss Meditec, Dublin, Calif.), HRT (Heidelberg Retinal Tomograph, Heidelberg Engineering, Vista, Calif.) and Stratus OCT (optical coherence tomography, Carl Zeiss Meditec).

“With our insurance carriers in Texas, these technologies are reimbursable every 6 months for glaucoma. They will pay for the OCT for the retina on a more frequent basis, but it must be medically necessary,” he said in an interview. “For example, if you have a patient with cystoid macular edema who is on treatment to subside that, obviously you are not going to wait 6 months to see if that is working.”

Dr. McCall said his practice sometimes follows such a condition on a monthly basis until it is resolved.

“The main thing is to establish that this is medically necessary,” he said. “In cases where we have shown the medical necessity, we have not been questioned.”

According to John A. Gazaway, OD, of Broadway Vision Clinic, Eagle Grove, Iowa, the coverage of these procedures sometimes depends on whether the insurance is a private carrier or Medicare. “Frequently, private insurance carriers try to model themselves after Medicare, but sometimes they set their own rules,” he told Primary Care Optometry News.

He said in his practice experience, instruments such as the HRT, GDx and OCT are covered for glaucoma once a year without question.

“If you can document the need for it for something else, you can probably do it twice a year and it will be OK,” he said. “With most insurers, documentation is obviously the most important part.”

Dr. Gazaway said some of these instruments have modules for retinal and macular edema. He said his office has been reimbursed in cases of branch retinal vein occlusions or in cases where retinal edema is displayed or suspected.

“None of these tests are valid to submit for routine eye care; you have to have a diagnosis-driven reason to perform the test,” he said. “That is where your documentation of symptoms or signs comes in – something you have seen or something the patient has reported.”

These tests may be justified and reimbursable in cases where a condition is being followed for progression, Dr. Gazaway said. “If you feel a condition is increasing in intensity, especially macular edema, you do that test again to prove it,” he said. “That has also been paid without disputes.”

New level of care, profitability

According to Albert Morier, OD, a private practitioner located in Albany, N.Y., screenings with instruments such as the GDx, HRT and OCT are nearly standard of care.

“You generally don’t say an instrument is standard of care until most practitioners have it,” he said in an interview with Primary Care Optometry News. “However, these instruments add a new dimension and level of care to your practice and provide added profitability. Certainly, they bring a ‘wow’ factor to patients and families, and that cannot be undervalued.”

Instruments provide different information

According to Dr. McCall, who owns the GDx, HRT and Stratus OCT, practitioners who own all three instruments must find a way to maximize the technologies so that they “pay for themselves.”

“Most people choose one of the three and do not have all three,” he said. “In fact, very few of us have all three.”

Dr. McCall said he owns all three instruments because he sees a large number of geriatric patients in his practice, and each instrument provides him with unique and valuable information.

“I feel like I get more information on evaluation of the retinal nerve from the GDx, and I’m comfortable with that,” he said. “We also incorporate tonography and calculate the blood flow to the back of the eye through tonography.”

Dr. McCall said he uses the OCT primarily for the retina. “There is nothing that comes close to the accuracy of looking at the layers of the retina like the OCT,” he said. “It is living histology, it is an excellent instrument.”

He said the HRT is useful in gleaning information about cupping. “I love to have that piece of information that the HRT gives you that nothing else does,” he said. “I like the format of the HRT image; I like being able to see the rim. It is also easy to explain cupping to the patient with this instrument.”

Dr. McCall said these instruments essentially pay for themselves through the valuable information they provide, as well as patients’ recognition and appreciation of superior technology. “Even though I may run the GDx and HRT on the same pattern to get a more thorough diagnostic evaluation, I will only be paid for one. We file the code under the diagnosis of glaucoma once in a 6-month period,” said Dr. McCall.

John D. Coble

“We also have some software that can tie it all together in the exam room,” he said. “In any of my six exam rooms, we can pull up the GDx information, the HRT information, the 30-2 Humphrey Visual Field (Carl Zeiss Meditec) and the calculated blood flow, all on the same screen together. Our patients realize that no other practice in East Texas can provide the same services.”

John D. Coble, OD, FAAO, a private practitioner from Greenville, Texas, told PCON, “I like the GDx nerve fiber analyzer technology for glaucoma diagnosis and follow-up. It is quick, easy and reliable. The OCT can be used to monitor glaucoma, but I feel its greatest asset is in the retinal findings. It is a powerful tool with which to observe macular holes, cystoid macular edema, drusen and other retinal abnormalities.

“Although I wouldn’t use the Optomap to follow patients for treatment, it is extremely useful for early detection that may go unnoticed in routine or wellness exams, especially in the peripheral retina,” he added.

Proper coding

Understanding when and how to bill for the GDx, HRT and OCT is an important aspect of maximizing their usefulness to your practice.

According to Robert P. Wooldridge, OD, FAAO, director of the Eye Foundation of Utah, the national Center for Medicare and Medicaid Services (CMS) indicates guidelines of two scans per year for glaucoma patients and one scan a year for glaucoma suspects.

Robert P. Wooldridge

“CMS has indicated that the scans are less valuable in cases of advanced glaucoma, and that the scans may not be indicated in such cases,” he told PCON. “Of course, all examinations and procedures billed to Medicare should be based on medical necessity to the individual patient.”

Dr. Wooldridge said some Medicare carriers have more stringent requirements and limitations. He advised practitioners to consult their individual carrier for the requirements specific to their region.

Dr. Coble has filed for GDx reimbursement with Medicare and many major insurance companies and has had no problems. “I file them with a 92135 CPT and an ICD-9 of 365.01, 365.11, primarily,” he said. “Any of the glaucoma codes should go through without a problem.”

Many macular diagnosis codes tend not to be a problem for the OCT, Dr. Coble added.

“A GDx should only be used annually, unless there are circumstances that would require greater frequency, such as glaucoma that is not controlled,” he said. “In those cases, several GDx scans in the first year may be warranted.”

Once the glaucoma is under control, Dr. Coble said, once a year would be sufficient again. “Only do a test when it is medically necessary,” he said. “Don’t do it just because you can.”

“Self-pay” tests

Some technologies, such as the Optomap Retinal Exam (Optos North America, Marlborough, Mass.) are considered “self-pay” tests. For those with this technology in their practices, the question is whether to add the test to the exam fee or present it to the patient as an additional test.

“In our office, we have discovered that self-pay tests are not covered by certain carriers, and if you simply increase your exam fee, you are maxing out and going above what a third-party payer might pay for that exam,” said Mark A. Slosar, OD, FAAO, a practitioner in Lake Forest, Calif. “If you simply incorporate that fee into the exam and you max out, you are not really getting paid for it.”

Dr. Slosar said in his office, the Optomap is billed as a standalone fee on top of the examination fee. He said because he views all patients as needing the test, he does not present the additional fee as optional.

“It’s our belief that it is an integral part of a comprehensive exam, so it is part of our exam now,” Dr. Slosar told PCON. “We tell the patient up-front that since they were last here, we now perform the Optomap Retinal Exam, and there will be an additional fee.”

Dr. Slosar said, occasionally, a patient might question the necessity of the Optomap exam. Once he demonstrates the instrument for the patient, however, there is rarely a need for further convincing.

“Once we show them the image, and we show them how much more we can learn about their eye than we did previously, they are usually very impressed,” he said. “They recognize that it is a higher level of care.”

Dr. McCall said his practice has simply raised the exam fee to cover the Optomap, and they perform it on all patients.

“Because we have so many geriatric patients who will have retinal problems, it is a part of our normal exam,” he said. “The only exception we make is if someone is young and healthy and on a managed care plan. We give these patients the option to decline the test, but, in most cases, we do the Optomap on everybody.”

Dr. McCall added, however, that charging for the Optomap as an additional test is probably the most practical approach for most practices.

“Most of the doctors I talk to do it as an up-sell and try to get a higher penetration rate,” he said. “I agree that is probably the best way to put the Optomap in your practice and generate revenue. It’s just not the way we do it. We have a lot of Medicare and Medicaid patients, and these are the ones who need it and can’t pay for it.”

For more information:

• John A. McCall, Jr., OD, is a Primary Care Optometry News Editorial Board member, a private practitioner and senior vice president of vendor relations for Vision Source. He can be reached at 711 East Goliad Ave., Crockett, TX 75835; (936) 544-3763; fax: (936) 544-7894; e-mail: jmccall@visionsource.com.
• John A. Gazaway, OD, can be reached at Broadway Vision Clinic, PO Box 459, Eagle Grove, IA 50533; (515) 448-3813; e-mail: Vis142@aol.com.
• Albert Morier, OD, in private practice. He can be reached at 35 Hackett Blvd. #1, Albany, NY12208; (518) 262-2575; e-mail: amorier1@nycap.rr.com.
• John D. Coble, OD, FAAO, is in private practice. He can be reached at 3005 A Joe Ramsey Blvd., Greenville, TX 75401; (903) 454-1886; fax: (903) 455-3055; e-mail: drcoble@eyecareofgreenville.com.
• Robert P. Wooldridge, OD, FAAO, is director of the Eye Foundation of Utah. He can be reached at 201 East 5900 South, Salt Lake City, UT 84107; (801) 268-6408; fax: (801) 262-9216; e-mail: RPWOD@aol.com.
• Mark A. Slosar, OD, FAAO, is in private practice. He can be reached at 23002 Lake Center Dr., Lake Forest, CA 92630; (949) 454-1064; fax: (949) 454-4111; e-mail: drslosar@southcountyeyecare.com. Drs. McCall, Gazaway, Coble, Wooldridge and Slosar have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned. Primary Care Optometry News could not determine if Dr. Morier has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.