Coding and Reimbursement
Glaucoma Test Reimbursement
Here's the latest information about what Medicare covers -- and how to make sure you get paid in a timely manner.

BY SUZANNE L. CORCORAN, COE

Q: Which diagnostic tests will Medicare cover for glaucoma?

The more common tests covered by Medicare include:

• visual fields (92081, 92082, 92083)
• fundus photography (92250)
• gonioscopy (92020).

Less frequently used tests include:

• serial tonometry (92100)
• ultrasound biomicroscopy (76513)
• B-scan biometry (76512).
• relatively new test for glaucoma is scanning laser ophthalmoscopy (SLO), coded as 92135.

Q: What are the documentation requirements for diagnostic tests?

Most diagnostic tests share certain documentation requirements to support claims for reimbursement. The common elements are:

• indications for testing, which may include symptoms, suspected disease, or chronic disease
• an order for the test (This should be part of the physician's plan.)
• test results (i.e., photos, printout, drawing, notes)
• interpretation of the test
• physician's signature.

The CPT descriptions of documentation requirements for many ophthalmic diagnostic tests include the phrase, ". . . with interpretation and re-port." This refers to a short narrative in the medical record that explains the test results (if possible). The interpretation should include a notation about the reliability of the test results (i.e., whether the patient was compliant, and the quality of the photos), as well as a diagnosis and the impact the test results will have on the course of treatment (if any).

The report doesn't have to be on a separate form or page, but it should be clearly defined as a discrete entry, distinct from the rest of the exam notes. For some tests, this report can be written directly on the printout from the instrument (e.g., a visual field).

Q: Does Medicare pay for these diagnostic tests with an office visit or with other tests?

With a few limitations, Medicare will reimburse an exam as well as a diagnostic test performed on the same day. It also covers concurrent testing, with the exception that Medicare's National Correct Coding Initiative treats SLO and fundus photos as mutually exclusive, meaning that you would be reimbursed for fundus photography only. Many Medicare carriers also discourage performing SLO and visual fields on the same day.

Q: How often can these tests be performed?

The short answer is "as often as medically necessary." The American Academy of Ophthalmology has published practice guidelines. In addition, many Medicare carriers have local medical review policies (LMRPs) that address some of these tests.

The table below shows the frequency of glaucoma testing on Medicare beneficiaries by ophthalmologists. The numbers are drawn from calendar year 2000 data and represent average utilization, rather than upper limitations. (Keep in mind that a practice with a large percentage of glaucoma patients will probably have higher utilization than the averages shown in the table.)

SLO is still used infrequently compared to other tests such as visual fields because the equipment isn't yet owned by many practices. Over time, however, use of SLO is expected to exceed that of visual fields because SLO is defined as "unilateral," whereas the other glaucoma tests are defined as "bilateral."

Generally, use of diagnostic tests for glaucoma continues to increase. But with proper documentation and appropriate utilization of these valuable ancillary services, you shouldn't have a problem getting reimbursed.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800)399-6565 or via email at scorcoran@corcoranccg.com.