We have a physician who states all screening tests are not covered by Medicare and thus billable to the patient. We obtain an advance beneficiary notice (ABN) for OCTs prior to cataract surgery and file with a –GA modifier. Is this correct?

Answer: 

No, additional screening or rule out test are not billable to the payer or the patient. From the National Coverage Determination (NCD) Publication Number 100-3, Manual Section Number 10.1  “…where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented.”

Review EyeNet® Savvy Coder Cataract Controversies for more on this topic. 

Find links to current Medicare administrative contractor (MAC) local coverage determinations (LCD) at  aao.org/lcds.
Cataract surgery checklists can be found in Coding Assistant: Cataract and Anterior Segment.