New Tests Becoming Standard of Care
Various tests are available to help you diagnose and follow your glaucoma patients. Here's how to get properly reimbursed for them.
By Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., San Bernardino, Calif.

A variety of auxiliary tests accompany examinations of glaucoma patients or suspects. (The most important diagnostic tests with corresponding current procedural terminology [CPT] codes are listed in the table below.)

In this article, I'll discuss critical reimbursement principles, documentation guidelines and coding hints, as well as some utilization parameters you can use as benchmarks.

The basics

Proper reimbursement for diagnostic tests depends on:

• Coverage for the service
• Ample justification for the service
• Appropriate documentation of the service
• Proper coding on the claim form (CPT and ICD-9)
• Regulations governing reimbursement of the service.

These requirements are often misunderstood. For example, some eyecare providers expect reimbursement for tonometry. This test is considered an incidental component of an eye exam and seldom merits discrete or incremental reimbursement.

One common misunderstanding results from misreading 92100 as a CPT code to describe tonometry. The correct definition is serial tonometry, which entails at least three measurements at different times on the same day. Some eyecare providers use this code to describe measurement of diurnal curves. It often applies to cases of acute angle closure.

Even when tonometry is performed on a separate day, no distinct procedure code describes this service other than an eye exam. Clever schemes to obtain extra reimbursement for tonometry constitute fragmentation or
a la carte billing for a package of services. Because the sum of the parts usually is greater than the whole, extra dollars flow to the practice until the abuse is identified and stopped.

Comprehensive eye exams (92004, 92014) include gross visual fields. Consequently, this simple test is required, not optional, when you perform a complete evaluation of the visual system. This is significant because less reimbursement is assigned to intermediate eye exams, the next lower exam in the hierarchy, if the documentation in the chart isn't sufficient to describe a comprehensive exam. Of course, a more intense visual field examination, such as a tangent screen, is acceptable as an alternative to confrontation fields.

Benchmarking your practice

Medicare and other third party payers are concerned that diagnostic tests are justified. They monitor utilization rates to identify potentially abusive situations where the tests are used too often. The table above describes the utilization rates of tests per 100 eye exams, based on Medicare's 2000 BESS (Part B Extract and Summary System) data for the country. You can compare your own practice patterns to Medicare's utilization data by tabulating payments for a significant time period, say 3 months.

These utilization rates are benchmarks, not limits or ceilings, nor do they pertain to glaucoma alone. In practices with a fellowship-trained glaucoma specialist, it's common to find much higher utilization rates. This probably occurs because the specialist sees patients with more profound disease and spends proportionately less time with the general patient population. Clinicians who treat glaucoma infrequently have lower utilization rates. Also, practice patterns vary geographically.

Standard of care

Professional societies publish recommended standards of care for the treatment of some conditions, including glaucoma. From these standards as well as discussions with glaucoma specialists, it's possible to describe the usual frequency for these tests in most patients. Clearly, the extraordinarily difficult patient is a special case and not a useful reference point. The table below describes typical practice patterns for these tests where the clinician is satisfied with the control of the disease. More frequent testing is indicated for patients whose disease is not stabilized.

A visual field (VF) is the most common auxiliary test in glaucoma management. Three levels exist (92081, 92082, 92083). The last digit corresponds with the number of isopters in the test. For example, a threshold field with 3 or more isopters is an extended VF (92083).

Note that CPT explicitly requires an interpretation of the results of this important test. Usually, this is a short narrative describing the reliability of the results, the findings, any changes since the last field (if available) and the clinician's impression and assessment. Don't forget to sign the note.

A technician may administer the test -- this is called the technical component of the VF -- but the test is incomplete without the professional component (your interpretation). The interpretation need not occur on the same day that the VF is administered, but it should occur very soon after the test and before submitting
a claim.

The value of VFs is well established, but obvious scotomas occur long after optic nerve damage has begun. Thus, subtle changes in the optic nerve's appearance are early warning signs of glaucoma. For that reason, some clinicians examine the disc under high magnification and describe these changes in the medical record. This is considered an element of the office visit and only in complex cases does it warrant a separate charge as extended ophthalmoscopy. Medicare carriers list diagnoses for which this service is payable; simple glaucoma usually isn't included, but glaucoma complicated by inflammatory disease or neovascularization is sometimes identified.

Scanning computerized ophthalmic diagnostic imaging (92135) is another way to detect glaucoma early. Several instruments will map the topography of the optic disc and measure the thickness of the nerve fiber layer. Most Medicare carriers and many other third party payers cover this test. As this equipment becomes more widely available, we expect this test will become the standard of care.

Finally, at the end of 1996, Medicare published a policy to ensure that the doctor who orders diagnostic tests is responsible for the management of some aspect of the patient's care. If a doctor can't or won't use the test results to treat the patient, then he shouldn't order the test. In this context, "treatment" may include referral to another physician if the test results indicate a need for therapy which would be better provided by someone else.