Coding & Reimbursement

The once-in-awhile UBM test is uncommon no longer

Payers cover a variety of indications, so learn how to code for it.

By Suzanne L. Corcoran

Once an uncommon test, ultrasonic biomicroscopy has been garnering increased interest from some ophthalmologists. If you’re one of them, here’s what you need to know about coding for it.

Q. What is ultrasonic biomicroscopy?

A. Ultrasonic biomicroscopy (UBM) is an imaging technique that uses high-frequency ultrasound to produce high-resolution images of the anterior segment of the eye.¹

Q. What are the indications for UBM?

A. UBM imaging of the anterior segment is indicated where direct visualization with slit lamp is not feasible, such as structures behind the iris that cannot be directly seen using routine examination techniques. Third-party payer coverage policies usually contain a variety of indications, including:

• Anterior segment neoplasms

• Adhesions and synechiae

• Ciliary body disorders

• Dislocated lens or IOL

• Glaucoma

• Iris abnormalities

• Trauma to the globe

Q. What CPT code describes UBM?

A. CPT 76513 (Ophthalmic ultrasound, diagnostic; anterior segment ultrasound (immersion) water bath B-scan or high resolution biomicroscopy) describes this service. This code only describes testing by ultrasound; CPT directs, “For scanning computerized diagnostic imaging of the anterior ... segment using technology other than ultrasound, see 92132 …”

Q. What documentation is required to support a claim?

A. A physician’s order and interpretation are required for this claim. Make sure the interpretation discusses the results of the test and treatment (if any); a brief notation such as “abnormal” does not suffice. In addition to the patient’s name and date of the test, good documentation includes the following:

• Physician’s order – UBM to assess iris mass

• Technician – John Smith, ROUB

• Reliability of the test – Reliable

• Patient cooperation – Good cooperation

• Findings – Diffuse thickening of iris from 1 to 3 o’clock

• Assessment, diagnosis – Refer to Oncology for work-up of suspected iris melanoma

• Impact on treatment, prognosis – Wait for tumor work-up to decide on surgical treatment

• Physician’s signature

– I.C. Better, MD

Q. Is UBM covered by Medicare and other third-party payers?

A. Yes, when the test is performed for a covered indication and when medical necessity exists.

CMS defines 76513 as a unilateral procedure, so reimbursement is per eye. The 2015 national Medicare Physician Fee Schedule allowable for 76513 is $97.38. Local wage indices adjust this figure in their respective areas. Other payers set their own rates.

Be sure to denote the eye with “RT” or “LT” appended to 76513. When the test is performed bilaterally, bill on two lines, or one line with modifier -50 and units “1” and increase your fee accordingly.

This test is subject to Medicare’s Multiple Procedure Payment Reduction. This reduces the allowable for the technical component of a second or lesser-valued test when more than one test is performed on the same day.

Q. What is Medicare’s supervision requirement for UBM?

A. According to Medicare, this test requires direct supervision; that is, the physician must be present in the office and immediately available. It does not mean, however, that the physician must be present in the room where the test is performed.

Q. If UBM is performed for a noncovered indication, who is responsible for reimbursement?

A. Ask the patient to assume financial responsibility for the charge. Explain to the patient why the test is necessary, and that Medicare or other third-party payers will likely deny the claim. A financial waiver can take several forms, depending on insurance:

• An Advance Beneficiary Notice of Noncoverage (ABN) is required for services if Part B Medicare coverage is ambiguous or doubtful. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.

• For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

• For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.

Q. Is UBM bundled with other services?

A. According to Medicare’s National Correct Coding Initiative (NCCI), 76513 is bundled with CPT codes 76512, 92132 and some other less commonly used codes. If these bundled services are billed together, Medicare honors the claim for the lower-valued code; it denies the claim for the higher-valued test.

Q. How often may this test be repeated?

A. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from Medicare and other payers. OM

REFERENCES

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