Back to the Basics: Testing Services, Part 1

From A-scans to visual fields, ophthalmologists order and perform a lot of tests.

High volume of any test also results in third-party payer audits. Best practices research each payer’s requirements for documentation beginning with high volume tests, so when that inevitable request for records arrives, the practice is so well-prepared there is no recoupment.

Where Are Testing Services Located In CPT?

Testing services are located in the radiology, eye and ocular adnexa and category III codes for new technology.

Which Tests Are Based on Physician Work Versus Those That Can Be Delegated to Staff?

Tests that can be delegated have a technical component represented by modifier -TC and a professional component represented by modifier -26. Tests that are valued by physician work are not divided by -TC/-26. These tests include:

• 92020 Gonioscopy (separate procedure)
• 92071 Fitting of contact lens for treatment of ocular surface disease
• 92072 Fitting of contact lens for management of keratoconus, initial fitting
• 92100 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (e.g., diurnal curve or medical treatment of acute elevation of intraocular pressure
• 92201 Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor
• 92202 Ophthalmoscopy, extended; with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral
• Ophthalmodynamometry

What Are the Documentation Requirements for Tests That Are Delegated?

If the physician performs any test, naturally there is no documented order. But if it is a test that is typically delegated, your documentation must show that the physician performed the test personally. Otherwise, auditors will deny the claim because of a missing order.

Pull a few records where testing was performed. Answer these questions:

1. Is there a documented order in the medical record (not on the superbill or encounter form) that states which test by name? Not solely visual field, but which of the three visual field options for example.
2. Does the order state which eye(s) should be tested?
3. Does the exam note indicate what makes the test(s) medically necessary?
4. Has the physician provided the interpretation and report that includes a physician signature or initials and date of the interpretation?

Practices trying to streamline their schedule often get creative. Although it may sound wise to have standing orders for tests that all new patients undergo, the payer reality is that all new patients must be examined by the physician and then order any medically necessary tests. Standing orders and/or screening tests are never billable to insurance even when pathology is found.

What Are the Three Levels of Supervision for Delegated Testing Services?

Medicare Part B assigns one of three levels of supervision for each test that can be delegated. The levels are:

1. General supervision: The test is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. 
2. Direct supervision: A physician of the practice must be present and immediately available to furnish assistance and direction throughout the performance of the procedure.
3. Personal supervision: A physician must be in the room during the performance of a test.

Payers that do not recognize Medicare’s three levels of supervision only recognize direct supervision. 

Where the physician is when a test is performed must be proven in an audit.