Ask the Coding Experts: Comparative billing reports raise questions on glaucoma patient treatment and coding
Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.
From the November/December 2015 edition of AOA Focus, pages 48-49.
In October 2015, the Centers for Medicare & Medicaid Services (CMS) issued Comparative Billing Reports (CBRs) to 6,500 doctors of optometry.
These reports provided information about a doctor's billing patterns for certain services. This data was intended to give providers an opportunity to compare themselves to their peers, check their records against CMS' data and review Medicare guidelines to ensure compliance.
One of the data sets included in the reports provided information on the % of glaucoma patients who received visual fields CPT 92082-83 and scanning laser imaging codes (SCODI) CPT 92133-92134 within 90 days.
Based on the data provided by CMS, the national average for the percentage of glaucoma patients with both a visual field examination and SCODI study within 90 days was 37% from July 1, 2014, to June 30, 2015. The average by state during the same time period ranged from as low as 26% to as high as 65%.
Several doctors who received the CBRs contacted the AOA inquiring as to whether it is appropriate to report these two services within 90 days.
There is no national policy prohibiting the use of these two services within 90 days. However, doctors of optometry should be aware that there are certain Medicare contractors who have policies that speak directly to this issue.
For example, First Coast Service Options Inc. has a local coverage determination that indicates that with regard to glaucoma patients, "Patients with 'moderate damage' may be followed with scanning computerized ophthalmic diagnostic imaging and/or visual fields. One or two tests of either per year may be appropriate. If both scanning computerized ophthalmic diagnostic imaging and visual field tests are used, only one of each test would be considered medically necessary, as these tests provide duplicative information."
Additionally, CGS Administrators LLC, the Medicare contractor for Ohio, has a policy which indicates:
- In patients with moderate glaucomatous damage, alternating the use of SCODI and visual field tests within correct time intervals will be considered appropriate, and may increase the sensitivity of detecting glaucomatous damage. Performance of SCODI and visual field tests on the same day, or separated by a short period of time (within three months) is usually not considered medically necessary. However, there may be instances in which each test is needed to determine the patient's status and thus, treatment. The contractor expects use of both tests on the same day or during short intervals will be the exception rather than the rule.
There are also non-Medicare payers who have specific policies regarding the performance of visual fields and SCODI. For example, Health Net Inc. indicates that the health plan considers scanning computerized ophthalmic diagnostic imaging not medically necessary for patients with advanced glaucoma. The plan's policy indicates that for these patients, visual field is the preferred method of evaluation.
Many doctors of optometry see a benefit in providing SCODI and visual fields testing within three months of each other based on the patient's glaucoma status. As with all services billed, doctors should be aware of any payer reimbursement policies and be certain that clinical documentation fully supports the provision of any procedures or tests reported.
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Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.