Payment for Screening by optomap Retinal Exam (Optos)
FREQUENTLY ASKED QUESTIONS:
PAYMENT FOR SCREENING BY optomap® RETINAL EXAM
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q What is an optomap® screening fundus photo?
A It is an ultra-widefield fundus photo acquired by an Optos® retinal imaging device and interpreted by a physician. The full color image is high resolution and captures a 200 degree image in a single capture through a dilated or undilated pupil using red and green laser wavelengths. The optomap digital image can be reviewed with the Optos proprietary software and shared with other physicians. According to the company, Optos has cloud storage which fulfills all regulations related to data backup and restoration requirements.
The optomap fundus photo by an ophthalmologist or optometrist is indicated for detection of diseases or disorders that manifest in the posterior segment of the eye.
Q What does the chart documentation or electronic medical record contain besides the digital images?
A In addition to the digital images or a reference to where they are stored, the chart should contain:
- the patient’s name and date of the test
- appropriate chart notes about the results, and
- the signature of the physician
Appropriate documentation includes interpretation of the test results and a notation of the findings and assessment. When the results do not identify pathology or abnormalities, it is sufficient to note “normal fundus” (V72.0). When screening does reveal disease(s) or abnormalities, a more extensive note is warranted including findings, impression and/or diagnosis.
Q What are the attributes of a screening program with the optomap?
A Screening is differentiated from other diagnostic testing by several features.
- Screening is part of a wellness program to check for disease that may otherwise go undetected.
- Screening is not required by medical necessity; it’s optional.
- The physician recommends the optomap fundus photo prior to every complete eye examination.
- The optomap screening fundus photo is performed before the patient is examined by the ophthalmologist or optometrist.
- All patients are screened unless they decline.
As a general rule, if images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, it is not covered by most health insurance plans, including Medicare.
Periodic screening is reasonable so 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.
Q If screening with the optomap fundus photo finds pathology, may a claim for reimbursement be made?
A No. For Medicare and most other third party payers, screening is a non-covered service regardless of what is found.
The patient may be asked to return in the future for medically necessary diagnostic tests, ordered by an ophthalmologist or optometrist, to evaluate suspect-ted disease. Reimbursement for this claim is reasonable provided that the chart documentation is complete and supportive.
Q Which office visit should be billed with concurrent screening?
A The level of service as well as the corresponding CPT or HCPCS code will vary due to a number of factors, including:
- the patient’s complaint and the reason for the exam
- contribution of other systemic conditions that may necessitate a lengthy medical history
- the interval since the previous eye exam
- the extent of the exam and the number of elements documented in the medical record
- whether the exam includes dilation, and
- the physician’s assessment and treatment plan
Ophthalmologists and optometrists may use E/M codes (992xx), eye codes (920xx) or HCPCS codes (S062x). Other ancillary services may also apply, such as refraction (92015) or other tests.
Q How do we handle the extra charge in our billing system?
A In most cases, no claim will be sent to a third party payer because the patient is paying for a non-covered service and reimbursement is not sought. To avoid possible confusion at a later time, the patient’s statement should describe screening with an optomap screening fundus photo as “not medically necessary”. HCPCS code S9986 is useful for this purpose.
Medicare and many payers will not accept S9986. If a beneficiary insists a claim be filed, then report 92250-GY. 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.” Couple this with a diagnosis code indicative of screening, such as V70.0, “Unspecified general medical examination” which includes a general vision examination, or V72.0, “Special investigations and examinations, eyes and vision”.
Q How may we be compensated for an optomap screening fundus photo?
A Patients are given the opportunity to choose between an exam with or without the optomap fundus photo. After the benefits have been explained, the patient is advised of the extra charge for this service and may be asked to sign a financial waiver form. 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 have their own waiver processes and are not permitted to use the Medicare ABN form.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
Provided Courtesy of Optos, Inc. (800) 854-3039
Last updated February 11, 2020
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.
© 2020 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com