Reimbursement for Ultrasonic Biomicroscopy
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR ULTRASONIC BIOMICROSCOPY
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Q What is ultrasonic biomicroscopy ?
A Ultrasonic biomicroscopy (UBM) is an imaging technique that uses high frequency ultrasound to produce high resolution images of the anterior segment of the eye.1 UBM technology is available on the Ellex Eye Cubed™, Eye Prime™ and Eye One™ ultrasound units.2
Q What are the indications for UBM?
A UBM imaging of the anterior segment is indicated where direct visualization with slit lamp is not feasible. For example, structures behind the iris cannot be directly seen using routine examination techniques. Where third party payer coverage policies exist, they usually contain a variety of indications.
- Anterior segment neoplasms
- Adhesions and synechiae
- Ciliary body disorders
- Dislocated lens or IOL
- Iris abnormalities
- Trauma to the globe
Q What CPT code describes UBM?
A CPT 76513 (Ophthalmic ultrasound, diagnostic; anterior segment ultrasound immersion (water bath) B-scan or high resolution biomicros-copy, unilateral or bilateral describes this service. Note that the code was previously unilateral and is now defined as unilateral or bilateral.
Q Is UBM covered by Medicare and other third party payers?
A Yes, when the test is performed for a covered indication and medical necessity exists to perform or repeat the test.
Q What does Medicare allow for UBM?
A CPT 76513 is defined by Medicare as bilateral, so bill once whether one or both eyes are tested. The 2021 national Medicare Physician Fee Schedule allowable is $79.91. Of this amount, $47.45 is for the technical component and $32.45 is for the professional component. Medicare allowable amounts are adjusted in each area by local wage indices; other payers set their own rates.
This test is subject to Medicare’s Multiple Procedure Payment Reduction3 (MPPR). This reduces the allowable for the technical component of the lesser-valued test when two or more tests are performed the same day.
Q Must the physician be present while this test is performed?
A Yes. 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 What documentation is required in the medical record to support a claim for 76513?
A A physician’s order and interpretation are required. An interpretation should discuss the results of the test and treatment (if any). A brief notation such as “abnormal” does not suffice.
In addition to the patient’s name and the date of the test, good documentation includes the following.
- Physician’s order – UBM to assess iris mass
- Technician – John Smith, ROUB
- Reliability of the test – Reliable
- Patient cooperation – Good cooperation
- Findings – Diffuse thickening of iris from 1-3 o’clock
- Assessment, diagnosis – Refer to Oncology for work-up of suspected iris melanoma
- Impact on treatment, prognosis – Wait for tumor work-up to decide on surgical treatment
- Physician’s signature – I.C. Better, MD
Q How often may this test be repeated?
A In general, this and 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.
As a point of reference, UBM is uncommon within the Medicare program. For ophthalmology and optometry combined, it was reported less than 1 time per 1,000 eye exams in 2018.
Q Is UBM bundled with other services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), CPT codes 76512 and 92132 are bundled with 76513, as well as 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. Exam codes are not bundled with 76513.
Q If coverage is unlikely or uncertain, how should we proceed?
A Explain why UBM 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), a 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 Ellex, Inc.
Last updated April 6, 2021
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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