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  • How to Make Sure Your Billing for Tests Passes an Audit

    Recently, many practices have reported Supplemental Medical Review Contractor audits that involve anywhere from one to 50 records. Many of these chart audits had something in common: testing services. The following basic principles and cases will help you learn exactly when and how to bill for these services.  

    Know which tests you can’t bill for

    Not every test you perform can be submitted for payment. Confrontation fields and basic sensorimotor exams are countable exam elements for both E&M and Eye visit codes. You can’t bill them separately.

    Several other tests are also intrinsic to the exam:

    • Amsler grid;
    • Color vision test;
    • Glare testing;
    • Potential acuity measurement;
    • K readings;
    • Schirmer and Zone-Quick tests;
    • Ice pack test; and
    • Pilocarpine test.

    In addition, payer rules exclude screening tests and standing orders for tests in the office setting (i.e., every patient not refractable to 20/20 gets an OCT before seeing the physician). Even if you find pathology during the screening test, the patient is responsible for payment. Although it may make for a more efficient practice to perform the test before the patient sees the ophthalmologist, this doesn’t adhere to payer protocol.

    Unlike screening tests, most payers cover tests performed during the global period of surgery, whether related to the surgery or not. No modifier is necessary.

    Documentation requirements for delegated testing services

    All billable tests that you delegate and have non-physician staff perform require specific documentation. This includes:

    • A documented physician order in the medical record;
    • The name of the test;
    • A designation of which eye(s) should be tested; and
    • An interpretation of the test by you or another physician.

    The order for the test can be documented the same date the test is performed, or it may be documented in a previous encounter. Just make sure you include the order in the audit-documentation request.

    For the interpretation, payers don’t have specific guidelines for physicians; however, the findings should be concise and easily understood by a colleague or reviewer. Findings typically represent your thoughts when reviewing the test.

    Case 1: Schirmer tear test and punctal-plug insertion

    A new Medicare Part B patient presents with complaint of a dry, gritty foreign-body sensation in both eyes. She has tried over-the-counter drops without relief. The physician orders a Schirmer tear test and diagnoses bilateral dry eye. At the patient’s request, the physician inserts temporary plugs in the lower-right and -left puncta.  

    How to bill it:

    • Submit the claim with the appropriate level of E&M or Eye visit code. Don’t include modifier -25, which states that the exam is significantly and separately identifiable from the minor procedure performed the same day. Medicare Part B does not require modifier -25 on new patient exams.
    • Use CPT code 68761 -50 Closure of the lacrimal punctum; by plug, each, and place a “1” in the unit field. Remember the global period is only 10 days, making this a minor procedure.
    • You can’t submit a CPT code for the Schirmer tear test because it is part of the examination.

    Case 2: Biometry for patient with bilateral cataracts

    After a comprehensive exam, the physician diagnoses an established patient with bilateral visually significant cataracts. The patient, who has commercial insurance, requests surgery in the right eye, as the visual acuity is worse in that eye than the left.

    The surgeon documents an order for IOLMaster, and the staff preauthorize the biometry and cataract extraction with placement of an IOL in the right eye. The technician performs biometry, and the surgeon determines the lens power and signs the test.  

    How to bill it:

    • Submit the claim with CPT code 99214 Established patient E&M code, as it has the higher allowable than the 92014 Eye visit code for this commercial payer.
    • No modifier is necessary because surgery will be at least two weeks away, after preauthorization.
    • Also be sure to include CPT code 92136 -RT for the IOLMaster. The commercial plan does not follow Medicare’s rules for biometry billing. It is appropriate to wait and bill for the left eye once the second surgery takes place. Commercial payers do not always recognize the bilateral technical component of the biometry; instead payment includes the test and interpretation per eye.

    Case 3: 30-2 Visual field for patient in cataract surgery global period

    A patient in the global period for cataract surgery in the right eye presents for a glaucoma evaluation of the left eye. He is currently using glaucoma drops. The examination focuses on the primary angle-closure glaucoma. The same day, the physician orders a 30-2 visual field for both eyes, provides the interpretation and report and conveys the findings to the patient.

    How to bill it:

    • Submit the claim with 9XXXX for the appropriate level of exam and append modifier -24 to the exam. The modifier indicates this visit is not postop care, but rather a glaucoma evaluation of the unoperated eye.
    • Your chart note should indicate glaucoma evaluation of the left eye and not postop care.
    • Report only the glaucoma diagnosis, not the surgical diagnosis.
    • Finally, use CPT code 92083 Visual field. You do not need a modifier for tests performed during the global period.  

    For more information and helpful tips about testing services, be sure to check out these Academy coding resources:

    If you have additional coding questions, email

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    About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.