Medicare Reimbursement for Perimetry (Heidelberg)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR PERIMETRY

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Q What is perimetry?

A Perimetry, also known as visual field testing, is the systematic measurement of visual field function. The two most common types of perimetry are Goldmann kinetic perimetry and threshold static automated perimetry. Heidelberg’s Edge Perimeter performs both static automated perimetry and Flicker-Defined Form perimetry.

Q Does Medicare cover perimetry?

A Yes, when medically necessary. The National Coverage Determination for computer enhanced perimetry is NCD 80.9. It states that “Computer enhanced perimetry involves the use of a micro-computer to measure visual sensitivity at pre-selected locations in the visual field. It is a covered service when used in assessing visual fields in patients with glaucoma or other neuropathologic defects.” Many Medicare Administrative Contractors (MACs) also publish local coverage determination (LCD) policies that supplement the NCD; check your local policies.

Q Does NCD 80.9 supersede information in the local policy if my MAC publishes a more detailed policy?

A No. The introduction to the NCD 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, reg-ulations, rulings and general program instructions”.

Q Is perimetry covered for glaucoma suspect or age-related macular degeneration (AMD)?

A Medicare covers services for diagnosis and management of disease. Every MAC with a published policy includes coverage for “glaucoma suspect”. The term “glaucoma suspect” is used to mean that a patient has some (but not all) of the classic signs, or significant risk factors for the disease, including: 1) elevated intraocular pressure, 2) abnormal appearance of the optic nerve or asymmetric nerve cupping and 3) decreased visual field. Many MACs include AMD as a covered indication in their coverage policies. There are often limits on repeat perimetry for this indication.

Q What documentation is required in the medical record to support claims for perimetry?

A 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., poor cooperation)
test findings (e.g., scotoma)
comparison with prior tests (if applicable)
a diagnosis (if possible)
the impact on treatment and prognosis
physician’s signature

Q Is the physician’s presence required during perimetry

A Under Medicare, this test requires 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 test.

Q Why are there three different CPT codes for perimetry, and how do you distinguish between them?

A The three CPT codes (92081, 92082, 92083) identify different levels of complexity and detail in perimetry testing. Depending on the nature of the disease, the physician will select a suitable testing method. Extended threshold perimetry (92083) is most common.

Q How much does Medicare allow for these tests, and are there limits on billing with other services?

A The 2018 Medicare Physician Fee Schedule allowable amounts are:

These amounts are adjusted by local wage indices. Other payers set their own rates, which may differ significantly from Medicare’s fee schedule. These tests 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.

There are limitations. According to Medicare’s National Correct Coding Initiative (NCCI), perimetry codes are mutually exclusive with each other; if more than one test is done, bill only the largest. In addition, the E/M service 99211 is bundled with all of these tests.

Q How often may perimetry be repeated on a patient?

A The American Academy of Ophthalmology and many MACs have published guidelines for repeated testing. Typically, one field per year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and three times a year for extreme cases such as one-eyed patients or when the disease is progressing rapidly.

Q If coverage of perimetry is unlikely or uncertain, how should we proceed?

A Explain to the patient why perimetry 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 Heidelberg Engineering (800) 931-2230

Last updated March 25, 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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