Reimbursement for Ultrasonic Biomicroscopy (Accutome)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR ULTRASONIC BIOMICROSCOPY
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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. Accutome’s UBM Plus and UBM Plus Guarded employ this technology.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 exam-ination techniques. In existing third party payer coverage policies, 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 for it. 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., eyelid artifacts)
- test findings (e.g., dense posterior iris lesion)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
Q What does Medicare allow for UBM?
A CMS defines 76513 as a unilateral procedure so reimbursement is per eye. The 2015 Medicare Physician Fee Schedule allowable for 76513 is $97. This includes $60 for the technical component and $37 for the professional component (i.e., interpretation). These amounts are adjusted in each area by local wage indices. Other payers set their own rates.
Denote the eye with “RT” or “LT” appended to 76513. When the test is performed bilaterally, bill with modifier -50 and units “1” and increase your fee accordingly.
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 more than one test is performed on the same day.
Q Is the physician’s presence required while UBM is being performed?
A 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 If coverage of UBM is unlikely or uncertain, how should we proceed?
A Explain to the patient why UBM 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 may have their own waiver forms.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
Q What is the frequency of UBM in the Medicare program?
A UBM is uncommon within the Medi-care program. For ophthalmology and optometry combined, it was reported less than 1 time per 1,000 eye exams in 2013.
Q How often may this test be repeated?
A 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.
Q Is UBM 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.
1. Silverman RH. High-resolution ultrasound imaging of the eye – a review. Clin Experiment Ophthalmol. 2009 January; 37(1): 54–67. Link here. Accessed 05/29/15.
2. Accutome. Ophthalmic Ultrasound Equipment. Link here. Accessed 05/29/15.
3. CMS Transmittal 1104. August 2, 2012. Link here. Accessed 05/29/15.
Provided Courtesy of Accutome Inc. (800) 979-2020
Last updated July 1, 2015
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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