Reimbursement for Tests with CenterVue’s EIDON (CenterVue)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR TESTS WITH CENTERVUE’S EIDON
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Q What tests are performed with CenterVue’s EIDON?
A According to the company, EIDON is the first system to combine the advantages of SLO with the fidelity of true color imaging, setting new performance standards in retinal imaging. EIDON provides a 60° – 140o field, a live, confocal view of the retina, three different imaging modalities depending on the model, and may be done without dilation in many cases.1
There are 3 models of EIDON: EIDON, EIDON AF, and EIDON FA. Photographs of the macula, retina and optic nerve, with or without colored filters, are fundus photographs (FP); all models have this capability. EIDON AF and EIDON FA are both able to perform fundus autofluorescence (FAF).
The EIDON FA also has the capability to perform fluorescein angiography (FA). FA allows imaging of the vascular system in the retina and choroid after injecting fluorescein into a vein, and then taking serial images as the dye flows through the blood vessels. It allows the clinician to evaluate a wide variety of posterior segment eye disease.
Q Is FP covered by Medicare and other third party payers?
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.
Q Is FA covered by Medicare and other third party payers?
A Yes, for covered indications and as part of the overall evaluation and management of posterior segment eye disease. For example, FA following treatment of choroidal neovascularization (CNV) is necessary to monitor for recurrence or to detect additional treatable lesions.
Q What documentation is required in the medical record to support a claim for the 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
- test findings
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician signature
A form suitable for documenting the interpretation of FP and FA is available on our website. It may also be adapted for use within an EMR system.
Q What CPT codes are used to report these tests using CenterVue’s EIDON?
A Use CPT code 92250 (Fundus photography with interpretation and report) to report FP. The same code describes FAF. Use CPT 92235 (Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral) for FA.
Q What is the reimbursement for 92250 and 92235?
A Both codes are defined as bilateral so reimbursement is for both eyes. The 2019 national Medicare Physician Fee Schedule allowable for FP is $58.32. Of this amount, $36.00 is assigned to the technical component and $22.32 is the value of the professional component (i.e., interpretation). For FA, the value is $93.34, with $49.01 assigned to the technical component, and $44.33 for the professional component. These 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.
Both codes 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 How often may we re-test?
A Repeat testing is necessitated by disease progression, the advent of new disease, or planning for additional surgical treatment. Other-wise, repeated photos of the same, unchanged, condition are unwarranted or noncovered except in the case of suspected occult disease.
As a reference, Medicare utilization rates for claims paid in 2017 show that FP was associated with 9% of all office visits by ophthalmologists. That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 9 times. For optometrists, the utilization rate is about 14%.
Utilization for FA is much less, about 2% for ophthalmology and nil for optometry.
Q Are there bundles affecting these codes?
A Yes. According to Medicare’s National Correct Coding Initiative (NCCI), 92250 is mutually exclusive with SCODI of the posterior segment (92133, 92134). It is also bundled with ICG angiography (92240, 92242), although there is no problem billing 92235 and 92250 together. 92235 is mutually exclusive with fluorescein angioscopy (92230). Some Medicare Administrative Contractors (MACs) also discourage both FP and extended ophthalmoscopy at the same session unless the services are clearly not duplicative.
Q If coverage of FP or FA is unlikely or uncertain, how should we proceed?
A Explain to the patient why the test is necessary, and that Medicare or other third party payer will likely deny the claim. Obtain a financial waiver, which can take several forms.
- 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 may have their own waiver forms 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 CenterVue, Inc.
Last updated March 7, 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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