Optimizing Reimbursement for Retinal Diagnostic Testing
Riva Lee Asbell, Fort Lauderdale, FL

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• Gonioscopy – Gonioscopy has been unbundled from office visits since 1999 so don’t forget to code for it when performed in conjunction with an office visit. This test is a physician service with no separate technical component and does not require an interpretation and report as most other tests do.

• Autofluorescence – Good news – you can bill for this test with CPT code 92250 when you use a fundus photo camera with filter. Other types of instrumentation may not qualify.

• ABN Form – There is a revised ABN (Advanced Beneficiary Notice) form that must be used effective January 1, 2012. It differs from previous versions by the date that is printed on the bottom in tiny print (03/11). The form is available from http://www.rivaleeasbell.com
  /articles/ABN_2011.pdf or from https://www.cms.gov/BNI/
  02_ABN.asp where you can also read up on it from the CMS website. If a given diagnostic test is not covered for whatever reason (for a specific diagnosis, being considered experimental, etc.) the patient may be billed but an ABN should be signed and you must use Medicare’s form for Medicare patients. Without that form you will lose any adjudication in a dispute with the patient over payment. Old forms will not be accepted after January 1, 2012.
  
  
• EMR Charting and Documentation – Here’s some do’s and don’ts to help you when requests for copies of medical records are received from insurance companies for audits:
  • Make sure the order for each diagnostic test is entered in the medical record.
  • Make sure that a copy of the test images is included when records are requested for audit.
  • Make sure you include a print out of the extended ophthalmoscopy drawing when records are requested for audit.
  • Make sure the Interpretation and Report is entered into the medical record and is included in the print out. I have found with digital imaging that may have been read at a remote site (for example in the physician’s office), and not during the patient encounter, the Interpretation and Report may not be entered into the EMR but is incorporated into the separate imaging system’s data.
  • Signature issues are among the hottest ticket item in Medicare’s audits today. Absolutely make sure that the test is signed electronically. Keep up-to-date on the electronic and non-electronic signature and scribing requirements.
    
    
• Billing Rules and Regulations – Familiarize yourself with the following billing regulations so you know what to do and when to do it.
  • Unilateral versus Bilateral Tests. Make a listing of which tests can be billed for each eye and which ones cannot and code accordingly.
  • Avoid Denied Claims. Denials cost you time and money. Avoid those resulting from erroneous application of modifier 52.
  • Modifier 59 Utilization Abuse. Modifier 59 may be used to break code edit pairs under the National Correct Coding Initiative (the bundles) — overuse this and you will become a target for Medicare audits.