Ultrasonic biomicroscopy (UBM) isn’t common, but the frequency is increasing. Here’s what you need to know about this test.

Q. What is UBM?

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

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. For example, structures behind the iris cannot be directly seen using routine examination techniques. Where third-party payer coverage policies exist, they usually contain a variety of indications:

• Anterior segment neoplasms
• Adhesions and synechiae
• Ciliary body disorders
• Dislocated lens or IOL
• Glaucoma
• Iris abnormalities
• Trauma to the globe

Q. What documentation is required in the medical record for UBM?

A. A physician’s order with medical justification and interpretation are required. An interpretation should discuss 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 the 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 1-3 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, it is — when the test is performed for a covered indication and medical necessity exists to perform or repeat the test.

Q. What CPT code describes this test?

A. CPT 76513: Ophthalmic ultrasound, diagnostic; anterior segment ultrasound immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral.

Q. What does Medicare allow?

A. The 2021 national Medicare Physician Fee Schedule allowable is $79.91. Of this amount, $47.46 is for the technical component and $32.45 is for the professional component. Medicare allowable amounts are adjusted in each area by local wage indices; other payers set their own rates.

This test is subject to Medicare’s Multiple Procedure Payment Reduction, according to a January 2013 MLN Matters (https://tinyurl.com/yy97eezc ). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.

Q. What are Medicare’s supervision rules for 76513?

A. Under Medicare program standards, this test requires direct supervision. Direct supervision means the physician must be present in the office and immediately available. It does not mean that the physician must be present in the same room as the test.

Q. How often may this test be repeated?

A. Generally, 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. As a point of reference, UBM is uncommon within the Medicare program. For ophthalmology and optometry combined, it was reported less than one time per 1,000 eye exams in 2018.

Q. Is UBM bundled with other services?

A. Yes. According to Medicare’s National Correct Coding Initiative, CPT codes 76512 and 92132 are bundled with 76513 as well as some other less-common codes. If these bundled services are billed together, the claim for the lower-valued code will be honored; the claim for the higher-valued test will be denied. Exam codes are not bundled with 76513.

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

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

• An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful and may be useful where a service is never covered. 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 Part C Medicare (Medicare Advantage), a determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN.
• For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits is an alternative to an ABN. OM

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