Medicare Reimbursement for Visual Field Testing (OCULUS)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR VISUAL FIELD TESTING
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Q Does Medicare cover visual field testing?
A Yes. The National Coverage Determination for computer enhanced perimetry is NCD 80.9. Most Medicare Administrative Contractors (MACs) also publish local coverage determination (LCD) policies that supplement the NCD.
Q What are the indications for visual field testing?
A NCD 80.9 – Computer Enhanced Perimetry (Rev.1, 10-03-03) CIM 50-49 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.”
Check your MAC’s LCD for a detailed list of covered diagnoses.
Q Does this NCD supersede information in the local policy if my MAC publishes a more detailed policy?
A No. The introduction to the NCD manual states “Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions”.
Q Is visual field testing covered for glaucoma suspect?
A Yes, and every MAC with a published policy include this indication. Medicare covers services for diagnosis and management of disease. Physicians use the term “glaucoma suspect” to mean that a patient has some (but not all) of the classic signs of glaucoma, including: (1) elevated intraocular pressure, (2) pathologic changes in the anterior chamber angle, (3) abnormal appearance of the optic nerve or asymmetric nerve cupping, and (4) decrease in visual field.
Q Is visual field testing covered for age-related macular degeneration (AMD)?
A Sometimes. Many MACs include AMD as a covered indication in their coverage policies. These policies often include limits on repeat visual fields for this indication.
Q What documentation is required in the medical record to support claims for visual field?
A In addition to a physician’s order, 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
Q How often may this test be repeated on a patient?
A The American Academy of Ophthalmology and many MACs have published guidelines for repeated testing. Typically, one field per year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and three times a year for extreme cases such as one-eyed patients. In general, this and all diagnostic tests are reimbursed when medically indicated.
Q Is the physician’s presence required during visual field testing?
A No. Under the Medicare program standards, this test only needs 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 its performance.
Q Why are there three different CPT codes for visual fields, and how do you distinguish between them?
A The three CPT codes (92081, 92082, 92083) identify different levels of complexity and detail in perimetry testing. Depending on the nature of the disease, the physician will select a suitable testing method. Most often, an extended threshold perimetry (92083) is performed. Be sure medical necessity for the scope of testing is documented.
Q May I perform other tests or services on the same day as a visual field?
A According to Medicare’s National Correct Coding Initiative (NCCI), visual field testing codes are mutually exclusive with each other. For example, if you performed 92082 and, based on the results, decided to perform 92083, the test with the highest value would be billed and the lower level code would not. In addition, the E/M service 99211 is bundled with these tests. Although the visual field codes are not bundled with scanning computerized ophthalmic diagnostic imaging (92132 — 92134), some MACs may question the medical necessity for both tests on the same day. If they are both done, the chart documentation must justify the medical necessity for each test.
Q If Medicare does not cover a visual field, may I charge the patient?
A Explain to the patient why a visual field 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.
Provided Courtesy of OCULUS, Inc. (888) 284-8004
Last updated April 26, 2016
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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