iWellness Exam Prophylactic Testing (Optovue)
FREQUENTLY ASKED QUESTIONS:
iWELLNESS EXAM PROPHYLACTIC TESTING
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Q What is Optovue’s iWellness scan?
A Optovue’s iWellness scan is an assessment tool that uses Spectral Domain OCT technology to help identify retinal structural changes that may be associated with ocular disease. These early structural changes may not be visible with direct or indirect ophthalmoscopy.
Q What is the primary reimbursement issue associated with the Optovue iWellness scan?
A The question is determining who pays for the test. The party responsible for payment of the test depends on why the test is performed. For Medicare and most third party payers, assessment and wellness exams are not covered services.
Q What differentiates covered and noncovered diagnostic tests?
A Prophylactic testing is part of a wellness program to check for disease that may otherwise go undetected. It is not required by medical necessity for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; it is optional. The eye care professional recommends the test prior to a complete eye exam for all patients. Unless the patient declines, a technician performs the test before the doctor performs the eye exam.
Q When a physician utilizes the system for assessing consenting patients, who is responsible for payment?
A In most cases, the patient is financially responsible for assessments associated with a wellness program. Medicare and most third party payers do not cover these assessments even if disease is identified.1
Q If the iWellness scan reveals pathology and additional tests are ordered, would they be covered by insurance?
A Yes. If the clinician determines that there is pathology, additional diagnostic tests ordered by an eye care professional for a future visit, with an appropriate interval, are considered medically necessary to evaluate pathology and are covered services.
Q What documentation is required in the patient’s medical record?
A In addition to the digital image, the chart should contain:
- the patient’s name and date of the test
- suitable chart notes about the results
- the signature of the physician
- the precise location where the digital images are stored
Expected documentation includes interpretation of the test results and a notation of the findings and assessment. Without pathology or abnormalities, it is sufficient to note a finding such as “normal fundus” (Z01.00). If the SCODI scan does reveal disease(s) or abnormalities, a more extensive note includes findings, impression and/or diagnosis.
Q What should we tell patients about the iWellness scan?
A Patients are given the opportunity to choose an exam with or without the Optovue iWellness scan before the exam or testing begins. After the benefits of the test have been explained, the patient is advised of the extra charge for this service and may be asked to sign a financial waiver form. Payment for non-covered services is the patient’s responsibility.
Q May we bill the patient directly for these services?
A Yes. Explain to the patient why the iWellness scan is desirable, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver is advised and can take several forms, depending on insurance.
- An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
- For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN form.
Q How should we track the iWellness scan in our billing system?
A Assign a unique charge for the iWellness scan consistent with the time, resources, and purpose of the test. Because this is a non-covered service paid by the patient, a claim for reimbursement will not usually be filed.
If a beneficiary insists a claim be filed, then report 92134-GY. 92134 identifies SCODI of the posterior segment, retina, and modifier GY means an “Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.” The modifier notifies the payer to deny this claim.
Q Which diagnosis code is associated with the iWellness scan?
A The ICD-10 handbook instructs billers to use a code such as Z01.-, “Unspecified general medical examination”, which includes a general vision examination, or Z01.0-, “Special investiga-tions and examinations, eyes and vision”.
Q May we repeat the iWellness Exam test?
A Yes. Periodic wellness testing is reasonable as long as the interval between the tests is not short. An appropriate span of time will depend on the age of the patient as well as the patient’s medical history.
1 An exception is made when monitoring for ophthalmic pathology in patients on long-term therapy with high-risk medications, such as Chloroquine/hydroxy chloroquine. For more information, please request Corcoran’s FAQ on Plaquenil (Link here).
Provided Courtesy of Optovue, Inc. (866) 344-8948
Last updated January 28, 2020
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
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