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. It states that “Computer enhanced perimetry involves the use of a micro-computer to measure visual sensitivity at pre-selected locations in the visual field. It is a covered service when used in assessing visual fields in patients with glaucoma or other neuro-pathologic defects.” Most Medicare Administrative Contractors (MACs) also publish local coverage determination (LCD) policies that supplement the NCD; check your local policies.
Q Is visual field testing covered for glaucoma suspect or age-related macular degeneration (AMD)?
A All MACs with published policies in-clude glaucoma suspect. Medicare covers services for diagnosis and management of disease. The term “glaucoma suspect” means that a patient has some (but not all) of the classic signs of the disease, including: (1) elevated intraocular pres-sure, and (2) abnormal appearance of the optic nerve or asymmetric nerve cupping.
Many MACs include AMD as a covered indication in their LCDs. These policies often include limits on repeat visual fields for this indication.
Q Does NCD 80.9 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, reg-ulations, rulings and general program instructions”.
Q What documentation is required in the medical record to support claims for visual field?
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
Q Is the physician’s presence required during visual field testing?
A 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.
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 How much does Medicare allow for these tests, and are there limits on billing with other services?
A In 2020, the national Medicare Physician Fee Schedule rates are as follows (rounded).
These values are modified by local wage indices so actual payment rates vary. Other payers set their own rates, which may vary considerably. These tests 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.
In addition, according to Medicare’s National Correct Coding Initiative (NCCI), perimetry codes are mutually exclusive with each other. The E/M service 99211 is bundled with all of these codes.
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 or when the disease is progressing rapidly.
Q If coverage of visual fields is 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.
Provided Courtesy of OCULUS, Inc. (888) 284-8004
Last updated August 18, 2020
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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