Reimbursement for Ultrasonic Biomicroscopy
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR ULTRASONIC BIOMICROSCOPY
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
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 Ellex’ Eye Cubed™ 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 examina-tion 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 biomicroscopy) describes this service. CPT directs, “For scanning computerized diagnostic imaging of the anterior … segment using technology other than ultrasound, see 92132 …”
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 billable per eye. When the test is performed bilaterally, bill with modifier -50 and units “1” and increase your fee accordingly. The 2016 national Medicare Physician Fee Schedule allowable is $96.31. Of this amount, $60.15 is for the technical component and $36.16 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, OD
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
Q What is the frequency of UBM in the Medicare program?
A 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 2015.
Q Is this test bundled with other services?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 76513 is bundled with CPT codes 76512, 92132, 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. Eye and E/M exam codes are not bundled with 76513.
Q May we ever bill the patient for UBM testing?
A Yes; sometimes a physician may feel that UBM is merited even though his or her reasons do not comport with Medicare’s coverage policies. In the situation where Medicare might not cover the test, an Advance Beneficiary Notice of Noncoverage (ABN) should be signed by the patient prior to testing. Submit your claim as 76513-GA. 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, be sure to promptly refund the patient or show why Medicare paid in error.
Provided Courtesy of Ellex, Inc.
Last updated November 17, 1016
1 Silverman RH. High-resolution ultrasound imaging of the eye – a review. Clin Experiment Ophthalmol. 2009 January; 37(1): 54–67. Link here.
2 Ellex, Inc. UBM. Link here.
3 CMS Transmittal 1104. August 2, 2012. Link here.