Medicare Reimbursement for E-Swin Tearcheck – (E-Swin)
© Corcoran Consulting Group
Frequently Asked Questions:
1. What is the E-Swin tearcheck?
It is a diagnostic instrument for evaluating tear film quality of patients with dry eye syndrome. It incorporates a battery of tests that assess: blinking, hyperemia, demodex, tear breakup time, meibomian glands, the ocular surface, and tear meniscus. An Eye Fitness Test questionnaire scores (0-44) subjective signs and symptoms.
2. What CPT codes should we use to describe tearcheck?
Use CPT 92285, external ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophoto-graphy, stereo-photography), to report the imaging service when medically necessary. The images include: bulbar and palpebral conjunctiva (eye redness), eyelashes (Demodex), meibography, corneal staining (fluorescein), and tear meniscus.
To report a tear film stability exam using tearcheck, use 0330T, tear film imaging, unilateral or bilateral, with interpretation and report. The National Correct Coding Initiative edits treat 0330T as separate and distinct from 92285.
The Eye Fitness questionnaire and abortive blinking examination are incidental parts of an eye exam and not separately reported.
3. Does keratoconjunctivitis sicca (H16.22-), not specified as Sjogren’s, support 92285?
Yes, a recent MAC article, A57068, lists H16.22- as supporting medical necessity.
August 9, 2023
4. Is the physician’s presence required while external photography is being performed?
Under Medicare program standards, 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.
5. What documentation is required in the medical record to support claims for 92285 and 0330T?
A physician’s interpretation and report are required for each test. 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
- reliability of the test
- test findings (e.g., aqueous deficiency)
- comparison with prior tests (if applicable)
- the impact on treatment and prognosis
- physician’s signature
6. Does Medicare cover external photography and tear film imaging?
Sometimes. The key points that warrant coverage include:
- The photographs provide additional information not obtained during the exam
- The photographs aid in diagnosis and treatment of a disease or condition
- The photographs are taken to assist in assessing disease progression
Photographs taken merely to document disease are typically treated as an incidental service and not accorded separate reimbursement.
7. What does Medicare allow for external photography and tear film imaging?
CMS defines CPT 92285 as “bilateral”, so reimbursement is for both eyes. The 2023 national Medicare Physician Fee Schedule (MPFS) allowable for 92285 is $23.38. Of this fee schedule amount, $20.33 is assigned to the technical component and $3.05 is the value of the professional component (i.e., interpretation). Medicare allowable amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.
External photography is 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.
No specific amount is assigned to 0330T in the MPFS in 2023. Payment is determined claim by claim. This code is scheduled to sunset 12/31/23.
8. What is the frequency of external photography in the Medicare program?
Medicare utilization rates for claims paid in 2021 show that external photography was performed at 1% of all office visits by ophthalmologists or optometrists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service about 1 time.
9. How often may this test be repeated?
In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.
10. If coverage of external photography is unlikely or uncertain, how should we proceed?
Explain to the patient why external photography is necessary, and that Medicare or other third-party payor 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 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.
Last updated August 9, 2023
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe thisinformation is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over
time, and may be incorrect at any time following publication.
© 2023 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
Provided Courtesy of E-swin USA