Coding & Reimbursement

Using OCT for Screening: Who Pays?

By Suzanne L. Corcoran, COE

Some diagnostic tests may be performed as screening tests for patients who do not manifest disease but may be at risk. This month we discuss OCT in this context.

Q. Why consider using optical coherence tomography for screening?

A. The level of sensitivity of OCT devices currently on the market is extremely high. A screening OCT exam aims to identify very early signs of ocular and systemic disease that may first appear in the retina but that may not be visible through the use of traditional forms of ophthalmoscopy or photography. However, this raises questions. The first is who pays for the test; the second is the reason for the test.

Q. How does the reason for the test relate to reimbursement?

A. Screening is part of a wellness program to check for disease that may otherwise go undetected. It is not required by medical necessity; it is optional. The eyecare professional recommends the test prior to a complete eye exam for all patients unless they decline. A technician performs the test before the patient is examined.

The patient is responsible for charges associated with screening services; Medicare and most third-party payers do not cover screening services. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then the test is not covered (even if disease is identified).

Q. If a screening test reveals pathology and additional tests are ordered, would they then be covered by insurance?

A. Yes, the additional diagnostic tests ordered by an eyecare professional are considered medically necessary to evaluate pathology and are covered services.

Q. What should we tell patients about screening tests?

A. Explain to the patient the benefits of the test and that insurance will likely deny the claim. Advise the patient of the extra charge for this service and ask him to sign a financial waiver form. Payment for noncovered services is the patient's responsibility.

Notice of Exclusion from Benefits forms (one for Medicare and one for other payers) are used when the test is for screening purposes. These forms notify the patient that the service is not covered, either by statute or by the insured's policy, and that the beneficiary is financially responsible.

An Advance Beneficiary Notice of Noncoverage (ABN) informs the patient that Medicare coverage is uncertain. For example, an ABN is appropriate when a disease is suspected but not found or an indication is not covered by the local Medicare policy. Since this screening is statutorily noncovered, and to avoid confusion on the part of the patient, we recommend using a NEMB form for screening services, not an ABN.

Q. How should we track the screening service in our computer system?

A. Because this is a noncovered service paid by the patient, it is unlikely that a claim will be filed. For bookkeeping purposes and to avoid confusion for the patient, a distinct charge for the screening test should be made. HCPCS code S9986 “not medically necessary service” is useful for this purpose. If a beneficiary insists a claim be filed, then report 92133-GY or 92134-GY. Modifier GY means an “Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.” This modifier ensures a denial.

Q. May we repeat the screening test?

A. Yes. Periodic screening is reasonable as long as the interval between the tests is not short. An appropriate span of time will depend on the age of the patient as well as the patient's medical and family history.

Q. Does an analysis of the OCT justify an additional charge?

A. There are two parts to an OCT: (1) technical, and (2) professional. The technical part is the image. The professional part is the interpretation of the image by the physician. Each part merits a charge, although it is customary to combine them into a single fee when both parts are provided by the same enterprise. It is important to note that there is no value to OCT that is not interpreted, and there is potential malpractice risk if the physician fails to interpret the images.

Q. What documentation is required in the patient's medical record in addition to the screening digital image?

A. Expected documentation includes interpretation of the test results and a notation of the findings and assessment. Without pathology or abnormalities, it is sufficient to note a finding such as “normal fundus” (V72.0). When screening does reveal disease(s) or abnormalities, a more extensive note includes findings, impression and/or diagnosis, and plan. OM

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