CODING & REIMBURSEMENT

Reimbursement for OCT screening

By Suzanne Corcoran

Many practices are considering using OCT for screening. What do you need to know?

Q. Why consider establishing an OCT screening program?

A. OCT devices currently on the market have a high level of sensitivity. OCT used for screening aims to identify very early signs of eye and systemic disease that may first appear in the retina and may not be visible to traditional forms of ophthalmoscopy or photography.

Q. What reimbursement issues should we consider with a screening program?

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 practice may recommend the test to all patients prior to an exam; patients, of course, may decline. Commonly, a technician performs the test before you examine the patient.

Medicare and most third-party payers do not cover screening services, with limited exceptions. The patient is responsible for these charges. You should get the patient’s acknowledgement and acceptance of financial responsibility, in writing, prior to performing the screening test. An Advance Beneficiary Notice of Noncoverage (ABN) or Notice of Exclusion from Health Plan Benefits (NEHB) will serve as this notice and acceptance.

Q. How should we code?

A. Because this is a noncovered service paid by the patient, it is unlikely that you will file a claim. For bookkeeping purposes and to avoid confusion for the patient, however, make a distinct charge for the screening test. HCPCS code S9986 “not medically necessary service” is useful for this purpose.

If a patient requests 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. Use a diagnosis code that supports a wellness screening, such as V72.0 (Routine examination of eyes and vision). A comment on the claim that the test is being submitted for denial at the patient’s request is also helpful.

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 medical and family history as well as the patient’s age.

Q. Since the test is non-covered as screening, does Medicare limit our charges?

A. No. Pricing for screening tests is a private matter between the physician and the patient. You may collect any amount that is agreeable to both parties.

Q. If a screening test finds pathology and additional tests are ordered, would insurance then cover those tests?

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