Coding & Reimbursement

Addressing BFA Coding

By Suzanne L. Corcoran, COE

The Ocular Blood Flow Analyzer (BFA), manufactured by Paradigm Medical Industries (Salt Lake City), may have value to the clinician in assessing the early onset of some ocular diseases, such as glaucoma and diabetic retinopathy. Like other new technologies, there are significant questions about reimbursement for this test. I will address many of them in this column.

Q. What does the BFA measure?

A. The BFA is a pneumotonometer that measures IOP every 2 to 3 ms with an accuracy of 0.1 mmHg. The time variation of IOP is analyzed and used to calculate the pulsatile ocular blood flow (POBF). Measurements are as accurate as the Goldmann applanation tonometer, are highly reproducible and are not operatordependent. Normal values for POBF depend on age, sex, pulse rate and refractive error.

This information may have value to the clinician in assessing the early onset of disease caused by compromised blood supply to the eye. In particular, patients who have normotensive glaucoma or proliferative diabetic retinopathy may have insufficient blood perfusion.

Studies have shown that POBF is lower in patients with glaucoma, which supports the hypothesis that vascular factors are associated with this disease. POBF has a negative correlation with IOP; it decreases with increasing IOP.

Q. Does Medicare cover testing with the BFA?

A. Since there is no national policy related to BFA, coverage decisions are at the discretion of each Medicare carrier. Some carriers have published policies on reimbursement for diagnostic testing with BFA that state BFA is considered investigational and therefore is not covered by the Medicare program.

Q. Which CPT code is most appropriate?

A. When the BFA was first introduced, the manufacturer recommended CPT 92120 (Tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method) to report this test. However, effective Jan. 1, 2009, a new Category III CPT code has been assigned: Use 0198T (measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report) to describe testing with the BFA.

Category III CPT codes are a set of temporary codes for emerging technology, services and procedures. When a Category III code is assigned, it must be reported instead of a Category I code (i.e., 92120). The assignment of a Category III code neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice.

Also, the existence of a code does not mean there is coverage for the service by Medicare and other third-party payers. They frequently take some time to recognize Category III codes for payment. Until payers do recognize them, it is likely that your claims will be denied.

Q. If coverage is uncertain or unlikely, how should I proceed?

A. Explain to the patient:

1) the reason for the BFA test

2) that Medicare will probably deny the claim and

3) that the patient is responsible for the charge. Have the patient sign an Advance Beneficiary Notice of Non-Coverage (ABN) before the test. Submit the claim to Medicare with modifier -GA, indicating the presence of a signed ABN.

Provide a description of the procedure in the comment field of the claim. If the carrier will accept facsimiles, send an explanation of the procedure as well. You may collect your fee from the patient at the time of service. If Medicare pays your claim, promptly refund the beneficiary.

Q. What are the documentation requirements?

A. The chart should contain:

• an order for the test with medical rationale

• the date of the test

• the reliability of the test (e.g., poor due to corneal scarring)

• the test findings (e.g., number of cells/mm²)

• a diagnosis (if possible)

• the impact on treatment and prognosis

• the signature of the physician.

A form suitable for documenting the interpretation of this test is available on Corcoran's Web site.

Q. May we bill for a BFA test on the same day as other services?

A. Code 0198T doesn't have any payment policies, nor are there any NCCI edits published yet. As with other diagnostic tests, Medicare would likely bundle a technician exam (99211) on the same day.

Other office visits (920xx or 992xx) would not be bundled, presuming appropriate documentation of the visit. OM