Today’s advances in posterior segment imaging are mind-boggling; just think of all the technologies we have at our fingertips to assist in the early diagnosis of potentially debilitating diseases.
While integrating imaging technology for screening purposes is fairly common in ophthalmic practices, the associated coding and billing can sometimes create practice management mayhem—communication gaps with patients, coverage issues, insufficient documentation, economic issues and, of course, significant risk exposure for audit.
By definition, screening is based upon the assumption that the person is not yet diagnosed with a disease and a broad, indiscriminate protocol will identify those who either have the disease, are at risk but do not have the disease or are not at risk and do not have the disease. For coding and third-party billing purposes, screening does not meet the requirements of medical necessity; therefore, the code generally used is not a CPT code, but a Level II HCPCS code: S9986 – Not Medically Necessary Service.
A few ground rules are important to keep in mind when using screening tests and the S9986 code:
1. You must communicate to the patient that the screening test is not medically necessary.
2. You must explain to the patient that they are financially responsible for the cost of the screening, even if you find pathology.*
3. The test should be done prior to the patient seeing the physician to avoid any implied medical necessity.
The S9986 code is quite broad in its application because it doesn’t refer to a specific procedure, but rather a category of testing. For example, clinicians can use it to code a screening retinal image or a screening OCT, provided that in either case the screening image captured is different than the image that would be used to bill your fundus photograph (92250) or your OCT (92132, 92133, 92134). And here is where individuals create exposure.
Technological advances have created single instruments that can perform many types and levels of tests, and clinicians must be careful to choose the proper testing type and level.
For example, say a patient presents for a general exam as part of a managed care vision plan (MVCP). When given the option to have a pre-exam screening retinal image taken for a specific fee, the patient agrees. For these images, the instrument must be in the designated “screening mode.”
During the subsequent exam, the physician notes an area of concern in the retina that deserves further photo documentation. The physician writes the order for the fundus photo based upon the medical necessity established during the exam.
This second test, performed using the same instrument, must provide additional information (i.e., stereo images) for the physician—information not present in the screening image—that aids in the patient’s diagnosis, treatment and outcomes. This test can be performed on the same day as the screening or later.
The key is in the information provided. If the ordered images are the same as the screening or do not provide additional information, they should not be performed at all, as the primary tenet of medical necessity has not been met.
Assuming the burden of medical necessity was met and the test provided the additional information to qualify, the billing would be:
S9986 – payable by the patient
920X4 – copay as per MVCP
92015 – copay as per MVCP
92250 – billable to medical carrier, subject to specific co-pay/deductible guidelines
Just because the physician found pathology with the screening image doesn’t mean the patient fee is waived, nor does it mean an additional photo is required; also, patients identified as having disease are not eligible for yearly screening.
Advanced screening technology provides a tremendous advantage when identifying early disease. Proper application of the guidelines surrounding screening and medical necessity can provide your patients with the care they deserve and success for your practice.
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* Some carriers are now including retinal screening photos as part of their structured benefit package. Please follow the specific carrier’s policies in these situations.