EyeNet Magazine

Savvy Coder: Coding & Reimbursement

Coding for New Technology: The Optos Dilemma

By John M. Haley, MD, Member of the Academy Health Policy Committee, and Sue Vicchrilli, COT, OCS, Academy Coding Executive

A new scanning laser technique called Optos has been developed for evaluation of the fundus. On the company’s Web site and at meetings, the technique is presented as a quick fundus-screening technique that rarely requires dilation of the pupil and is offered as a tool for preventive medicine.

It appears the company is advocating substituting this test for a dilated fundus exam. To our knowledge, however, there are no peer-reviewed studies to suggest that this technique is comparable to a dilated fundus exam.

For billing purposes, CPT requires use of the code that most closely fits the clinical situation. In this instance, the CPT code that most closely fits the use of the scanning laser technology is 92135—which has the descriptor Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral—but the test does not meet the Medicare criteria for local coverage decisions for 92135. There is no support for the suggestion that 92250 Fundus photography with interpretation and report can be used for “pictures” obtained by scanning lasers. In addition, if one relies on the Optos technique rather than dilating the patient, one must bill a lower level Eye Code or E&M Code that does not require a dilated exam. Failure to do so exposes you to possible accusations of upcoding if a Medicare audit is performed.

We expect that this test at present will usually be a noncovered screening exam for which both Medicare- and privately insured–patients will need to pay out of pocket.

Medical Necessity
You should keep in mind the medical necessity rule: One cannot order screening tests for which there is no documentation of medical necessity prior to the test being ordered and then bill for the service if pathology is detected.

Documentation of baseline is not medically necessary under most circumstances and yearly documentation of normal or stable pathology is usually not considered medically necessary either.

If the scans are read at an outside facility rather than in the office, a professional fee cannot be charged under any circumstances.

New for 2005

Use the AAOE’s coding resources to find out how this year’s changes to the reimbursement regulations may affect your practice.

Coding Update audioconference. What’s new with the 2005 CPT, ICD-9 codes and Office of Inspector General’s 2005 work plan? On Tuesday, Jan. 11 at 11 a.m. PST, Academy coding executive Sue Vicchrilli, COT, OCS, will get you up to speed—and you won’t even have to leave your office.

To register for this one-hour audioconference ($110 for AAOE members; $145 for other registrants), phone 800-651-7916 or visit www.aao.org/audioconference.

CodeQuest program. One-day training programs, cosponsored with state societies, are scheduled for January in Arkansas, Georgia and South Carolina; for February in Arizona, Kentucky, North Carolina, Oklahoma, Tennessee and Utah; and for March in Minnesota, Texas and Washington.

For more information, visit www.aao.org/codequest.

Coding books. The AAOE offers 22 training and reference books for coding, all of which have been updated for 2005.

To see what’s available, visit www.aao.org/store and search by subject under “AAOE: Coding & Reimbursement.”

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