Medicare Reimbursement for Nidek MP-1S and MP-3 Microperimeter (Nidek)
FREQUENTLY ASKED QUESTIONS
Medicare Reimbursement for Nidek MP-1S and MP-3 Microperimeter
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Q Does Medicare cover testing with the Nidek MP-1S and the MP-3 Microperimeter?
A The MP-1S and MP-3 are capable of performing multiple tests. In addition to perimetry, the MP-3 also performs non-mydriatic fundus photography. Each device also performs a fixation exam, which is included in an eye exam and not separately payable. Perimetry and fundus photography may be payable in addition to an exam.
Q What are the reimbursement rules for fundus photography?
A Medicare covers fundus photography if the patient presents with a complaint that leads you to perform this test or as an adjunct to management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye, or as preventative medicine to screen for potential disease, then it is not covered (even if disease is identified). Also, this test is not covered if performed for an indication that is not cited in the local medical review policy; check with your payer for specific coverage limitations.
CPT code 92250 (Fundus photography with interpretation and report) best describes this test.
Q What code should we use to describe perimetry?
A There are three CPT codes (92081, 92082, 92083) that identify different levels of complexity and detail in perimetry testing. Depending on the nature of the disease, the physician selects a suitable testing method. Most often, an extended threshold perimetry (92083) is performed.
Q What are the indications for perimetry?
A NCD “80.9 – Computer Enhanced Perimetry (Rev.1, 10-03-03), CIM 50-49” states, “Computer enhanced perimetry involves the use of a micro-computer to measure visual sensitivity at preselected locations in the visual field. It is a covered service when used in assessing visual fields in patients with glaucoma or other neuro-pathologic defects.” Check your local coverage determination (LCD) policy for a detailed list of covered diagnoses.
Q Does this NCD supersede my local policy if my Medicare contractor published something more detailed?
A No. The introduction to the Medicare National Coverage Determinations Manual states, “Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions”.
Q Is perimetry covered for glaucoma suspect?
A Yes. Every Medicare contractor with a published policy includes this indication. “Glaucoma suspect” is used to mean that a patient has some (but not all) of the classical signs of the disease, including: 1) elevated intraocular pressure, 2) ab-normal appearance of the optic nerve or asymmetric nerve cupping, or 3) decrease in visual field.
Q What documentation is required in the chart for perimetry and fundus photography?
A In addition to the test results or a reference to where digital images are stored, the chart notes should contain these elements.
1. An order for the test with medical rationale
2. The date of the test
3. The reliability of the test (e.g., cloudy due to cataract)
4. The test findings (e.g., hemorrhage)
5. A diagnosis (if possible)
6. The impact on treatment and prognosis
7. Physician’s signature and date
Q How much does Medicare allow for these tests?
A Both perimetry and fundus photos are bilateral services and reimbursed the same whether one or both eyes are tested. The 2018 national Medicare Physician Fee Schedule allowances are:
The specific allowable for each area is determined by adjusting the national rate by local indices.
Q Is the physician required to present while these tests are performed?
A Not for Medicare. Under the Medicare program standards, these tests need only general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the procedure.
Q What about bundles with other services?
A According to Medicare’s National Correct Coding Initiative (NCCI), 92250 is mutually exclusive with scanning computerized ophthalmic diagnostic imaging (92133, 92134) and remote screening for retinal disease (92227).
In NCCI, perimetry codes are not bundled but they are mutually exclusive with one another. For example, if you performed 92082 and, based on the results, decided to perform 92083, then 92083 would be billed and 92082 would not.
Q How often can these tests be repeated?
A For perimetry, the American Academy of Ophthalmology and many Medicare contractors have published guidelines for repeated testing. Typically, one field every 12-18 months is warranted for borderline or controlled glaucoma with mild damage, once per year for controlled glaucoma with moderate to severe damage, twice a year for poorly controlled glaucoma, and up to four times a year for uncontrolled glaucoma. Special cases, such as one-eyed patients, also merit frequent testing.
There are no published limitations for repeated fundus photography. In general, all diagnostic tests are reimbursed “when medically indicated”. Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention from Medicare and other payers.
Provided Courtesy of Nidek (800) 223-9044
Last updated April 24, 2018
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. 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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