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 (I&R) 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 won’t 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 you’ve looked at it. When a carrier finds that an I&R hasn’t been completed, then the entire test is deemed to be invalid; this means that you’ll have to return the entire payment to the carrier, not just the amount for the professional component of the test.
Selecting Diagnosis with Diagnostic Tests
Medicare’s 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. 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.
Interpretation and Report (I&R)
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:
- An Interpretation and Report containing the three C’s—clinical diagnosis, comparative data, and clinical management—included 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. Medicare’s 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. 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; it’s 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 can’t dedicate the proper time and energy to ensure a properly functioning revenue cycle.
Medical Billers and Coders can assist you in taking control of your revenue cycle operations. We offer a full range of optometry billing services to make your practice’s billing system efficient, profitable, and compliant. We can help your practice excel at the entire revenue operations to become more thorough and efficient. To know more about our optometry billing services, contact us at info@medicalbillersandcoders.com/ 888-357-3226.
FAQs
1. What is the difference between diagnostic tests and screening tests in ophthalmology?
Diagnostic tests are performed based on medical necessity to confirm or rule out a condition and guide clinical decision-making. Screening tests, on the other hand, are preventive measures conducted without medical necessity to check for diseases. Screening tests are typically not covered by Medicare or most payers, and fees should be collected directly from patients.
2. Why is documentation of medical necessity important for diagnostic tests?
Proper documentation of medical necessity is crucial as it justifies why a diagnostic test was performed. Without it, third-party payers may deny reimbursement. Additionally, using an Advance Beneficiary Notice (ABN) and appropriate modifiers is recommended when there is a possibility of claim denial.
3. What is the role of Interpretation and Report (I&R) in billing for ophthalmological diagnostic tests?
The I&R is a critical component that includes the clinical diagnosis, comparative data, and how the test impacts the care plan. Without completing the I&R, the diagnostic test is considered incomplete, and providers may need to return the payment for both the professional and technical components.
4. How should diagnosis coding be handled for ophthalmological diagnostic tests?
If the test confirms a diagnosis, code the confirmed condition. If the test yields no diagnosis or normal results, code the signs or symptoms that prompted the test. Incorrect or non-existent diagnosis coding can negatively impact patients and lead to billing issues.
5. Can Medical Billers and Coders assist with optometry billing challenges?
Yes, Medical Billers and Coders provide comprehensive optometry billing services, including ensuring proper documentation, handling diagnostic vs. screening test distinctions, and optimizing revenue cycle operations. Their expertise helps practices become efficient, profitable, and compliant. For assistance, contact info@medicalbillersandcoders.com or 888-357-3226.
