Reimbursement for Tests with CenterVue’s Compass (CenterVue)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR TESTS WITH CENTERVUE’S COMPASS
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Q What tests are performed with CenterVue’s COMPASS?
A According to the company, COMPASS is a white-light LED scanning ophthalmoscope (SLO) combined with an automated perimeter that performs standard visual field testing while actively tracking the retinal position. The fundus-related visual field test (VF) provides 30-2, 24-2 and 10-2 patterns; also a supra-threshold test (24-2 ST).
COMPASS simultaneously provides color confocal images of the retina, as well as measurements of retinal threshold sensitivity. The tests can be done under non-mydriatic conditions. The SLO in COMPASS yields a 60° wide fundus image.1
Q Does Medicare cover VF with the COMPASS?
A Yes, when medically necessary. The National Coverage Determination for computer enhanced perimetry, NCD 80.9, states, “Computer enhanced perimetry involves the use of a micro-computer to measure visual sensitivity at preselected locations in the visual field. It is a covered service when used in assessing visual fields in patients with glaucoma or other neuropathologic defects.” Most Medicare Administrative Contractors (MACs) also publish local coverage determination (LCD) policies that supplement the NCD; they are usually much more specific.
Many MACs include AMD as a covered indication in their VF coverage policies but often include limits on repeat tests for this indication. Every MAC with a published policy on VF includes glaucoma suspect. Medicare covers services for diagnosis and management of disease. The term, “glaucoma suspect”, is used to mean that a patient has some (but not all) of the classic signs of the disease, including: (1) elevated intraocular pressure, (2) ab-normal appearance of the optic nerve or asymmetric nerve cupping and (3) decrease in visual field.
Q Does Medicare cover fundus photography (FP) performed with the COMPASS?
A Yes, if the patient presents with a complaint that leads you to perform this test as an adjunct to evaluation and management of a covered indication. If images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then the test is not covered (even if disease is identified). Also, it is not covered if performed for indications not in the local coverage policy. FP is frequently performed for both glaucoma and retinal disease; for example, all MACs with a FP policy include age-related macular degeneration (AMD).
Q What documentation is required in the medical record to support claims for these tests?
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 patient 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
A form suitable for documenting the interpretation of diagnostic tests is available on our website. It is adaptable for use as an EMR system template.
Q What CPT codes are used and what is the reimbursement for these tests?
A Codes and Medicare fees are shown below. These codes are defined as bilateral so reimbursement is for both eyes. All tests require an interpretation and report. The 2019 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 include both technical and professional components, and 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.
Q Are there bundles affecting these codes?
A According to Medicare’s National Correct Coding Initiative (NCCI), the E/M service 99211 is bundled with these tests. VF are mutually exclusive with each other; if more than one test is done, bill only the largest. 92250 is mutually exclusive with SCODI-P (92133, 92134), and bundled with ICG angiography (92240, 92242). There is no edit prohibiting VF and simultaneous FP if both are medically necessary and properly interpreted.
Q How often may these tests be repeated on a patient?
A The American Academy of Ophthalmology and many MACs have published guidelines for repeated testing for VF and FP. Typically, one field per year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and more often for extreme cases such as one-eyed patients or when the disease is progressing rapidly. The use of OCT of the optic nerve will also affect VF frequency.
The need for repeat FP depends on whether the fundus has changed on exam.
Q If coverage of these tests are unlikely or uncertain, how should we proceed?
A Explain why the test 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 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.
1 CenterVue, Inc. Link here.
Provided courtesy of CenterVue, Inc.
Last updated April 2, 2019
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 this information 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.
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