EyeNet Magazine

Savvy Coder: Coding & Reimbursement
What You Need to Know About Special Testing Services, Part One
By Sue Vicchrilli, COT, OCS, Academy Coding Executive

If auditors were to scrutinize your documentation of special testing services, how would you fare? Make sure your coding is in compliance by familiarizing yourself with these 10 issues.

1. Everyone in the office must read the Medicare state-specific Local Coverage Determinations (LCDs) for documentation requirements. Most states have policies for corneal topography, extended ophthalmoscopy, fundus photography, fluorescein angiography, pachymetry, ophthalmic A- and B-scans, optical coherence tomography and visual fields. For a list of Medicare Web sites, visit www.aao.org/aaoesite/coding.

2. Medicare recognizes three levels of supervision: general, where the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure; direct, where a physician of the practice must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure; and personal, where a physician must be in the room in attendance during performance of the procedure.

Non-Medicare payers only recognize direct supervision.

3. In ASC settings, there are no RVUs for special testing services.

4. When codes have unilateral payment, you can’t bill for both eyes unless there is pathology in both eyes.

5. If a nonphysician performs a test, there must be a written order specifying: right eye, left eye or both eyes; which test; and medical necessity.

6. All special testing services require interpretation and report. There are no specific guidelines. The documentation can be on the test or in the medical record. The technician/photographer performing the test is responsible for getting the test to the physician for the interpretation and report.

7. Testing services can be billed (and paid) within the global period of a major surgery when medically indicated.

8. Nearly all testing services are bundled in the Correct Coding Initiative (CCI) with CPT code 99211, known as the technician code. Audits by Medicare and the Office of Inspector General (OIG) reported incorrect coding of 99211 in these cases. Some offices were erroneously billing this level of exam for the time the technician spent performing the test.

9. Technical and professional components for testing services are recognized by Medicare, but not by most non-Medicare payers.

10. Coding rules are different for a patient who is in a skilled nursing facility (SNF), but has a special test performed in an ophthalmology office. The test’s professional component (–26) is billed to Medicare Part B and the technical component (–TC) to the SNF.


Which Codes Will Payers Audit?

Payers tend to focus their audits on those codes that are used most often.

PHYSICIAN TESTING SERVICES. Based on Medicare’s 2005 statistics, the three most frequently used CPT codes have been:

  • 92226, subsequent ophthalmoscopy, which was billed approximately 2 million times by ophthalmologists.
  • 92225, extended ophthalmoscopy, came in second with just over 1 million billings.
  • 92020, gonioscopy, was billed 800,000 times.

DELEGATED TESTING SERVICES. Again based on Medicare’s statistics for 2005, the six most frequently used CPT codes have been:

  • 92135 is known by many names—OCT, optic nerve scan, scanning computerized diagnostic imaging, Heidelberg, GDx—and was billed more than 3 million times.
  • 92083, level 3 visual field, was billed nearly 2.5 million times.
  • 92250, fundus photography, was billed just over 1.5 million times.
  • 92235, fluorescein angiography, was billed slightly less than fundus photography.
  • 76519, A-scan, was billed 1.25 million times.
  • 92136, IOLMaster, was billed 800,000 times.


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