Coding & Reimbursement

Coding for Ancillary Vision Tests

By Suzanne L. Corcoran, COE

Ancillary testing before cataract surgery or YAG capsulotomy may be valuable. This month we discuss Medicare's rules regarding the tests you might choose to perform.

Q. Does Medicare cover ancillary vision tests, such as brightness acuity testing (BAT), potential acuity meter (PAM) and contrast sensitivity (CS) testing?

A. BAT, PAM testing and CS testing prior to cataract surgery or YAG capsulotomy are covered, but only as a part of a covered exam or consultation. They are not covered as stand-alone services.

Each of these tests is recognized as a supplemental method for evaluating vision, but Medicare and other third-party payers consider them to be incidental components of the associated eye exam. Incidental services may not be unbundled and billed separately to the patient, nor may you circumvent the bundle by getting an Advance Beneficiary Notice signed.

Q. May we use 92499 (unlisted ophthalmological service) to claim reimbursement for BAT, PAM or CS tests?

A. Do not use 92499 to unbundle ancillary vision testing from the remainder of the office visit for Medicare, or for other payers, unless specifically instructed to do so.

Q. When should we perform BAT as part of an exam to evaluate cataracts or posterior capsular opacity (PCO)?

A. Most Medicare Administrative Contractors (MACs) comment on the use of BAT in their coverage policies for cataract surgery. A BAT test is merited for patients complaining of symptoms of glare. However, it is not universally applicable to all patients with cataracts. Similar guidelines apply to patients with PCO who may be candidates for YAG laser capsulotomy.

Most MACs do not give specific instructions about BAT testing. Cigna Medicare recently published the following guideline: “Glare testing, if performed, must be done with either the low or medium setting for light intensity.”

Without payer instructions, physicians are expected to follow the manufacturer's directions and perform the test in an appropriate manner to obtain information about the patients vision. BAT is intended to provoke a possible visual limitation induced by normal lighting conditions for the patient. Some postpayment audits have found the test unsupported when performed at the highest setting because the results are considered contrived if the patient does not regularly cope with very bright light.

Q. What are the indications for contrast sensitivity testing?

A. CS testing is useful as an auxiliary means of assessing visual difficulties in patients who test well with a traditional Snellen chart. A Snellen chart employs high contrast (i.e., black letters on a white background).

Many people can read the 20/20 line and still complain of visual difficulties, such as driving at night (i.e., low-contrast conditions). This may be due to optical aberrations of the visual system, contact lens problems, ocular pathology, complications related to medications and ocular manifestations of systemic diseases.

Q. When is PAM testing indicated?

A. One of the criteria used by payers to determine the medical necessity of cataract surgery or YAG laser capsulotomy is the expectation of improved vision following surgery. For patients with multiple conditions affecting their vision, for whom an accurate manifest refraction cannot be obtained, a PAM is useful to help differentiate the vision change caused by the developing cataract from the decreased vision from other source(s) and to estimate the potential visual outcome.

Q. Are the results of a BAT, PAM or CS test sufficient to justify cataract surgery?

A. By themselves, these tests are insufficient to justify cataract surgery. Criteria for cataract surgery include:

• objective evidence of a cataract
• reduced best-corrected visual acuity (BCVA)
• subjective lifestyle complaints expressed by the patient
• a good prognosis for visual improvement

Consult your specific MAC policy for BCVA. Most include a requirement of 20/50 or worse. When a patient complains of glare and the BCVA is better than 20/50, BAT or CS testing may be indicated. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.