Understand Ophthalmological Diagnostic Testing

1. Understand Ophthalmological Diagnostic Testing Medical Billers and Coders

2. 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.

3. 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.

4. 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.

5. 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.

6. 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. MedicalBillersandCoders 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.

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