Reimbursement for Tests with the OCULUS Keratograph 5M (OCULUS)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR TESTS WITH THE OCULUS KERATOGRAPH 5M
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Q What tests can be performed with the OCULUS Keratograph 5M®?
A The Keratograph 5M is a multipurpose diagnostic instrument for evaluating the anterior segment using topography, photography, and other imaging. The instrument can perform multiple tests, including:
- Corneal topography (CPT 92025)
- Anterior segment photography (CPT 92285)
- Zernike and Fourier analysis of the cornea
- Contact lens fitting
- Tear meniscus height
- Lipid layer thickness
- Meibomian gland imaging
- Tear film break-up time
These tests supplement the physician’s evaluation and management of corneal and lacrimal disease, planning for anterior segment surgery, and contact lens fitting. Some features of the Keratograph 5M are particularly useful for patient education.
Q Does Medicare cover corneal topography (CT)?
A Sometimes. The diagnosis is the key factor in most policies, but it varies; some areas have no current policy. Coverage may be provided when CT is used for the diagnosis and management of corneal disease, disorders such as keratoconus or irregular astigmatism, injury, and postoperatively following corneal transplant surgery. When CT is only refractive-based, such as with regular astigmatism, no coverage is provided. For a representative Local Coverage Determination (LCD) policy, link here.
Q Does Medicare cover external ocular photography?
A Yes, although no national Medicare policy exists, reimbursement is at the discretion of each contractor. Indications vary between LCDs. Photographs of static or longstanding conditions are not usually billable. Other payer policies likewise vary, so check them periodically.
Q Does Medicare cover Zernike and Fourier analysis?
A No. Because this test is refractive in nature, it would be coded as refraction (CPT 92015). Within the Medicare program, refraction is not a covered service. Zernike and Fourier analysis is additive to the basic refraction since it moves beyond sphere, cylinder and axis which are commonly found in most glasses and contact lenses. In CPT, modifier -22 is used with a code to report an unusual service that is greater than that usually required for the listed procedure.
Q Does Medicare cover contact lens fitting?
A Contact lens fitting for routine refractive error not associated with aphakia or pseudophakia is not covered. Contact lens fitting for keratoconus (CPT 92072) may be covered.
Q Does Medicare cover any of the other tests in the first question (i.e., keratometry, tear meniscus height, et seq.)?
A The other tests shown in the first question, not already discussed, are incidental to the exam and are not separately billable. They do have significant patient educational value.
Q What documentation is required in the medical record?
A In addition to the images, the medical record for each test should include:
- order for the test with medical rationale
- date of the test
- the reliability of the test (e.g., unstable tear film)
- test findings (e.g., irregular astigmatism due to worsening keratoconus)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
Q Is it possible to bill for more than one test on the same day?
A Yes. Multiple tests may be billed on the same day if there is sufficient justification for each. Assessing different problems using different tests is one justification, as occurs when corneal topography is performed on the same date as external photography. 92025 and 92285 are subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.
Q How frequently may I perform diagnostic testing with the OCULUS Keratograph 5M?
A Generally, tests may be repeated as often as is medical necessary. Some reasons are:
- During the eye exam that precedes the order for another test, the physician has formed a suspicion that the patient’s condition has changed for the worse due to:
- objective evidence of vision loss
- new symptoms or complaints
- a recent surgical intervention
- exam findings of disease progression
- Earlier tests are no longer reliable.
- AAO’s Preferred Practice Patterns may suggest repeat testing at specific intervals
Q If Medicare does not cover the test(s) may I charge the patient?
A Explain to the patient why the test is necessary, 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 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 Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
Provided Courtesy of OCULUS, Inc. (888) 284-8004
Last updated May 2, 2016
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and 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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