Contrast sensitivity (CS) testing is a valuable tool for ophthalmology and optometry, so let’s review the reimbursement rules.

Q. What is CS testing?

A. CS refers to the ability of the visual system to distinguish between an object and its background. For example, imagine a black cat on a white snowy background (high contrast) vs a white cat on a white snowy background (low contrast).

Whenever visual acuity is reduced, CS is reduced as well. However, sometimes CS is reduced more than expected based upon the visual acuity alone. This means that if only visual acuity is tested, the visual disability of the person with relatively reduced contrast sensitivity will be underestimated.

Q. What are the indications for CS 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, ie, 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 (ie, low-contrast conditions). This may be due to optical aberrations of the visual system, contact lens problems, ocular pathology, complications related to medications or ocular manifestations of systemic diseases.

Q. How is the test performed?

A. CS tests can be conducted by various methods, including Pelli-Robson, Mars and Rabin. All use low-contrast letters. CS testing measures visual performance over a wide range of sizes and contrasts. The purpose of the test is to assess how well a person functions visually to see everyday objects such as faces and signs.

Q. What documentation is need for CS testing?

A. In addition to the CS printout or other output, the medical record should contain:

• The date of the test
• The reliability of the test (eg, attentive patient)
• The test findings
• A diagnosis (if possible)
• The impact on treatment and prognosis
• The signature of the physician.

Q. How is CS testing coded?

A. No specific code describes this test. As AAO explained in 2016, where CS testing is used to evaluate abnormal vision, it is an incidental part of an eye exam (www.aao.org/practice-management/news-detail/cpt-code-contrast-sensitivity-testing ).

Do not use 92499 (unlisted ophthalmological service) to unbundle CS testing from the remainder of the office visit unless specifically instructed to do so by a payer. Also do not use CPT 99172, which describes visual function screening. Screening is useful for identifying risk as part of preventative care or routine eye care and does not presuppose an abnormal condition or pathology. CS testing is valuable in this context as a sensitive measure of visual performance, particularly for federally mandated occupational health services. Medicare does not cover visual function screening; many other payers agree.

Q. Is CS valuable for telemedicine?

A. Yes. Patients self-administer the CS test at home and discuss the results with an ophthalmologist or optometrist during a telemedicine visit.

Q. When testing in-office, is the physician’s presence required?

A. Yes, because it is performed by a technician rather than a physician. For services that are considered “incident to” an office visit, direct supervision is required. Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

Q. How can we get paid for CS testing?

A. There are two ways you may be paid: as part of a covered service such as an eye exam, either in-office or via telemedicine, or as a non-covered service such as screening. Covered services are indicated for pathology or abnormalities while non-covered services, including screening, are billed to the patient.

An Advance Beneficiary Notice of Noncoverage (ABN; https://www.corcoranccg.com/products/forms/abn-advance-beneficiary-notice ) 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. An ABN may not be used to collect from the patient for services already covered by Medicare.

For non-Medicare payers, use a Notice of Exclusion from Healthcare Benefits (www.corcoranccg.com/products/forms/nehb-notice-of-exclusion-from-healthplan-benefits/ ) form when you test for screening purposes. This notifies the patient that the service is not covered — and that the beneficiary accepts financial responsibility. OM

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