Medicare Reimbursement for Ophthalmic B-Scan (Accutome)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR OPHTHALMIC B-SCAN

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Q  What is B-scan ultrasonography?

A  B-scan ultrasonography produces two dimensional, cross-sectional views of the eye and the orbit.  In ophthalmology, B-scan ultrasonography is a valuable adjunct to an eye exam when the physician’s view with the ophthalmoscope or biomicroscope is obstructed or obscured.  Accutome’s B-Scan Plus is a portable, high definition B-scan.

 

Q  What chart documentation is required to support this service?

A  CPT notes, “All diagnostic ultrasound examinations require permanently recorded images with measurements [when indicated]…A final written report should be issued for inclusion in the patient’s medical record.”  

A physician’s interpretation and report are required.  A brief notation such as “abnormal” does not suffice.  In addition to the images, the medical record should include:

  • order for the test with medical rationale
  • date of the test
  • the reliability of the test (e.g., patient movement)
  • test findings (e.g., circumferential RD, OS)
  • comparison with prior tests (if applicable)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • physician’s signature

 

Q  What CPT code describes ophthalmic B-scan?

A  CPT code 76512 is listed as: Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan).

 

Q  Does Medicare cover B-scan of the globe?

A  Yes, when the test is performed for a covered indication and medical necessity exists to perform or repeat the test.  There are numerous reasons an ophthalmologist might order this test.

Where third party payer coverage policies exist, they usually contain a variety of indications, including:

  • Amaurosis fugax
  • Dislocation of lens
  • Exophthalmos
  • Hyphema
  • Neoplasms
  • Ocular foreign body
  • Ocular manifestations of diabetes
  • Orbital cysts
  • Retinal detachment
  • Trauma to the globe

Medicare’s National Coverage Determination §10.1 also provides, “For patients with a dense cataract, an ultrasound B-scan may be used.”

 

Q  Is 76512 unilateral or bilateral?

A  CPT does not specify, but the Medicare Physician Fee Schedule defines this test is unilateral.  Other payers may have different policies.

 

Q  How much does Medicare allow for this test?

A  The 2015 national Medicare Physician Fee Schedule allowable for 76512 is $94.  Of this amount, $40 is assigned to the technical component and $54 is the value of the professional component (interpretation).  These amounts are adjusted in each area by local wage indices.  Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

76512 is 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.  When indicated and performed bilaterally, the test for the second eye is affected by MPPR even if no other testing is done on that date.

 

Q  Is the physician’s presence required while B-scan ultrasonography is being performed?

A  Under Medicare program standards, this test requires direct supervision.  Direct supervision means the physician must be present in the office and immediately available.  It does not mean that the physician must be present in the room where the test is performed.

 

Q  How often may B-scan be repeated?

A  In general, diagnostic tests are reimbursed when medically indicated.  Clear documentation of the reason for testing is always required.  Most often, the justification is an indication of progression of a chronic disease. 

 

Q  Is this test bundled with other services?

A  Yes.  According to Medicare’s National Correct Coding Initiative (NCCI), 76512 is bundled with CPT codes 76510, 76511, 76513, and some other less-common codes.  If these bundled services are billed together, the claim for the lower-valued code will be honored; the claim for the higher-valued test will be denied. 

 

Provided Courtesy of Accutome Inc.  (800) 979-2020

 

Last updated July 1, 2015

 

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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