Screening Testing with SCODI – Zeiss

FREQUENTLY ASKED QUESTIONS:

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Q: What do ZEISS’ CIRRUS™ HD-OCT and CIRRUS photo instruments do?

A: All of ZEISS’ CIRRUS HD-OCT and CIRRUS photo instruments use scanning computerized ophthalmic diagnostic imaging (SCODI) technology to help identify signs of structural changes that may be associated with ocular disease. These structural changes may not be visible with traditional forms of ophthalmoscopy.

Q: What reimbursement issues affect the use of SCODI for screening?

A: The primary reimbursement issue is determining who pays for the test. The party responsible for payment of the test depends on why the test is performed. In most cases, screening is not covered by medical insurance.

Q: When a physician uses SCODI for screening consenting patients, who is responsible for payment?

A: The patient is responsible for charges for preventative testing associated with a screening program. Medicare and most third party payers do not cover these services. If the images are taken as baseline documentation of a healthy eye or as a preventative measure to look for potential disease without an indication, then the test is not covered by a payer even if disease is identified.¹

Q: How are non-covered well-vision tests differentiated from covered diagnostic tests?

A: Prophylactic testing is part of a wellness program to check for disease that may otherwise go undetected. It is not required by medical necessity for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member; it is optional. The eye care professional may recommend the test prior to a complete eye exam for all patients. Unless the patient declines, a technician most often performs these screening tests before the doctor performs the eye exam.

Q: If the OCT scan reveals pathology and additional tests are ordered, would they be covered?

A: Generally, yes. Additional diagnostic tests ordered by an eye care professional on another day at an appropriate interval are considered medically necessary to evaluate pathology, and are covered services. A repeat OCT on the same day as screening would not be covered.

Q: What should we tell patients about an OCT scan?

A: Patients are given the opportunity to choose between an exam with or without SCODI. After the benefits of the test have been explained, the patient is advised of the extra charge for this service and may be asked to sign a financial waiver form. Payment for non-covered services is the patient’s responsibility.

Q: If we use a financial waiver form, what form do we ask the patient to sign?

A: A Notice of Exclusion from Health Plan Benefits form is used when the test is part of a wellness/screening program. This form notifies the patient that the service is not covered, either by statute or by the insured’s policy, and that the beneficiary is financially responsible.
Although it is permitted, we do not recommend the use of an Advance Beneficiary Notice of Non-coverage (ABN) form. An ABN informs the patient that Medicare coverage is uncertain. For example, an ABN is appropriate when a disease is suspected but not found or an indication is not covered by the local Medicare policy. Since this wellness test is statutorily non-covered in the Social Security Act §1862(a)(1)(A), and to avoid confusion on the part of the patient, we do not recommend an ABN form.

A Notice of Exclusion from Health Plan Benefits (NEHB) form is available on our website.

Q: What documentation is required in the patient’s medical record?

A: In addition to the digital image, the chart should contain:
1. the patient’s name and date of the test
2. suitable chart notes about the results
3. the signature of the physician
4. the precise location where the digital images are stored

Expected documentation includes interpretation of the test results and a notation of the findings and assessment. Without pathology or abnormalities, it is sufficient to note a finding such as “normal fundus” (Z01.00). If the SCODI scan does reveal disease(s) or abnormalities, a more extensive note includes findings, impression and/or diagnosis.

Q: How should we track the SCODI (OCT) screening scan in our billing system?

A: Because this is a non-covered service paid by the patient, it is unlikely that a claim will be filed. For bookkeeping purposes and to avoid confusion for the patient, a distinct charge for the SCODI (OCT) scan should be entered into the patient account. HCPCS code S9986 “not medically necessary service” is useful for this purpose, or you can create an internal code.

If a beneficiary insists that a claim be filed, then report 92133-GY or 92134-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.” This modifier ensures a denial. Couple this with a diagnosis code indicative of screening, such as Z00.-, “Unspecified general medical examination” which includes a general vision examination, or Z01.0-, “Special investigations and examinations, eyes and vision”.

Q: May we repeat the SCODI (OCT) screening test?

A: Yes. Periodic wellness testing is reasonable as long as the interval between the tests is not short. An appropriate span of time for this depends on the age of the patient as well as taking into account the patient’s medical history.

1 An exception is monitoring for ophthalmic pathology in patients on long-term therapy with high-risk medications, such as Chloroquine/hydroxy chloroquine. For more information, please request Corcoran’s FAQ on Plaquenil (Link here).

Provided Courtesy of ZEISS (800) 358-8258

Last updated January 1, 2017

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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