Point-of-care testing is becoming more popular in the average optometric practice as technology improves and weaves its way into our daily clinical care. Many of the testing devices are small and simple to use—but that doesn’t mean that coding for point-of-care testing can be taken lightly, nor is it something you should assume is “bundled” into an office visit. In fact, many point of care tests require that your office have a Clinical Lab Improvement Amendments (CLIA) waiver. (See “Get CLIA Certified for POC Testing” in " A Lab in the Palm of Your Hand?")

Lab tests are paid from a national laboratory fee schedule and don’t follow the RBRVS reimbursement model. CPT codes are designated in the 8XXXX range. Only those tests that have the “waived” designation can be performed in your office. For coding purposes, CLIA-waived tests are designated by the -QW modifier. 

Here are some common point-of-care tests that ODs perform:

TearLab (TearLab). CPT code 83861-QW: Microfluidic analysis using an integrated collection and analysis device, tear osmolarity.

Tear Testing May No Longer Be Covered?
Be aware of a recent development in dry eye testing (TearLab and InflammaDry): Some CMS carriers are proposing that neither test be covered due to inconclusive medical evidence that they affect the outcome of treatment.
Here is an excerpt from one CMS carrier (Novitas):

“Due to the lack of supporting data to demonstrate patient benefit from microfluidic analysis (tear osmolarity) or immunoassay analysis of tears relative to treatment choice and planning, disease outcome or evolution, Novitas considers tear testing for osmolarity and immunoassay analysis for other than infectious agent, antigen or antibody not medically reasonable and necessary. Subsequently, tear testing (83516, 83861) for the evaluation of dry eye or its associated disease entities is non-covered.”

If you’re testing both eyes and coding for it, this is what the claim form would look like:

  • 83861-QW-LT 
  • 83861-QW-RT

AdenoPlus (Rapid Pathogen Screening). CPT code 87809-QW: Infectious agent antigen detection by immunoassay with direct optical observation, adenovirus.

If you’re testing both eyes and coding for it, this is what the claim form would look like:

  • 87809-QW-RT
  • 87809-QW-LT

InflammaDry (Rapid Pathogen Screening). CPT Code 83516-QW: Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative, multiple step method.

If you’re testing both eyes and coding for it, this is what the claim form would look like:

  • 83516-QW-RT
  • 83516-QW-LT

Not All Tests Are Created Equal
However, not all point-of-care tests are clinical lab tests or require CLIA certification. For example, both point-of-care tests for macular degeneration—Macula Risk NXG (ArcticDx) and RetnaGene AMD (Sequenom)—are not billable tests because the test itself is performed by an outside lab and the OD only collects the clinical sample by method of a buccal (cheek) swab. Swabbing is not a distinct and separate procedure according to the CPT and therefore is part of the office visit. 

Tests for Sjögren’s disease (Sjö) and diabetes both require collection of blood, which may not be within the scope of practice in your state. Keep in mind that the patient may stick his or her own finger for the blood sample, but you may not be able to. Again, this is a sample collection only, but in this case is described with CPT code 36415 (routine venipuncture) and pays about $3. Be cautious, as one could argue that you really didn’t perform the procedure if the patient stuck himself or herself.

Point-of-care testing is certainly on the rise in optometry. Be sure that you follow the rules of medical necessity when ordering any tests. Follow the guidelines by properly obtaining your CLIA certification. Finally, be aware that carrier rules are ever-changing and may not support the use of testing as you see fit.

Send questions and comments to ROcodingconnection@gmail.com.