Medicare Reimbursement for Visual Field Testing (Zeiss)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR VISUAL FIELD TESTING

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Q:  What is visual field testing with the Humphrey® Field Analyzer (HFA™)?

A:  The term “visual fields” encompasses a variety of subjective tests to determine a patient’s scope of vision, both central and peripheral. This includes confrontational visual field testing, static perimetry and kinetic perimetry.

 

Q:  Does Medicare cover visual field testing?

A:  Yes, when medically necessary. The National Coverage Determination for computer enhanced perimetry, NCD 80.9, 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:  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:  Is visual field testing covered for glaucoma suspect or age-related macular degeneration (AMD)?

A:  Every MAC with a published policy indicates glaucoma suspect. 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 the disease, including: (1) elevated intraocular pressure, (2) abnormal appearance of the optic nerve or asymmetric nerve cupping and (3) decrease in visual field. 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:  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, and date

 

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 is not required to be present during the test.

 

Q:  What are the 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, since the HFA can test approp-riately at each code level. Be sure medical necessity for the scope of testing is documented.

 

Q:  What does Medicare allow for testing with the HFA?

A:  The 2017 national Medicare Physician Fee Schedule amounts are as follows. These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from Medicare’s.

Each code is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the second and/or lesser-valued test when more than one test is performed on the same day.

 

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 one another; the E/M service 99211 is bundled with these tests. Although the visual field codes are not bundled with OCT (92133-92134), 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 coverage of visual fields is unlikely or uncertain, how should we proceed?

A:  Explain to the patient why visual field testing 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 processes.
  • For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

Provided Courtesy of ZEISS 

Last updated August 8, 2017

The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, etc.  The reader is strongly encouraged to review federal and state laws, regulations, code sets (including 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. 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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