The surge of ocular surface disease (OSD) management in optometric practice has driven technology to the forefront. Now, it not only helps to diagnose and treat this disease state but also creates the opportunity to educate and motivate patients to begin and maintain their treatment regimen.
The issue with imaging, of course, is who is paying for it—and that depends on why the image is taken and the role it plays in diagnosing, treating or educating and motivating the patient.
New MGD imaging technologies provide images of the anterior surface of the eye for clinical evaluation of OSD. Much of the manufacturers’ literature also touts the marketing and educational value of the images to help patients have a better understanding of their clinical status. That, however, cannot be the primary reason for capturing an image and billing to a third-party carrier, even if it is reimbursable with their clinical diagnosis.
This is where we have to revisit the concept of medical necessity. According to Medicare, it is defined as:1
Services or supplies that are proper and needed for the diagnosis or treatment of the patient’s medical conditions, are provided for the diagnosis, direct care and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area and aren’t mainly for the convenience of the patient or the physician.
Just because you have a piece of cool tech that you want to use and a billable diagnosis doesn’t mean you have the green light to capture the image and bill the carrier. Taking the image for educational purposes and not billing the patient isn’t acceptable either because it demonstrates a discriminatory or biased approach to your billing decisions. If an image is clinically worthy to capture, it should be billed either to the carrier or the patient. If you have a philosophy of capturing images but only billing to the carrier, that wouldn’t be appropriate, and if you capture images and don’t bill the patient, that could be viewed as an inducement or biased decision-making.
My advice is, if your patient has clinical signs and symptoms of OSD and you order imaging to assist in diagnosing, following a diagnosis, treating or following the treatment, you have established proper medical necessity. The CPT codes you will most likely encounter are:
92285: external ocular photography with interpretation and report for documentation of medical progress.
92025: computerized corneal topography, unilateral or bilateral, with interpretation and report.
0330t: tear film imaging, unilateral or bilateral, with interpretation and report.
All of these tests require an interpretation and report with:
Clinical findings: pertinent findings regarding the test results.
Interpretation of the findings.
Comparative data: comparison to previous test results, if applicable.
Clinical management: how the test results will affect management of the condition/disease going forward:
Change, increase or stop medications.
Recommendation for surgery.
Recommendation for further diagnostic testing.
Referral to a specialist/subspecialist for additional treatment.
Don’t forget that the CPT clearly states, “interpretation and report by the physician is an integral part of the special ophthalmological services where indicated and that the technical procedures (which may or may not be performed personally by the physician) are often part of the service, but should not be mistaken to constitute the service itself.” Technically, a diagnostic test is not complete until the physician’s interpretation and report is finished.
New imaging technology provides a great opportunity for patients with this chronic disorder to receive a prompt diagnosis and proper treatment. But be sure to follow the basic rules of medical necessity and create a bullet-proof clinical record by including all elements required to meet the definition of the CPT code used. Don’t fall into the trap of using this technology in a cavalier manner with inconsistent billing patterns.
Send your own coding questions and comments to email@example.com.
|1. Centers for Medicare and Medicaid Services. Glossary—medical necessity. www.cms.gov/apps/glossary. Accessed August 22, 2017.|