Coding Q&A

The questions keep coming on coding for diagnostic testing

Coding Q&A

The Questions Keep Coming on Coding for Diagnostic Testing

Information Provided By Riva Lee Asbell

I have been receiving numerous questions regarding the coding rules for diagnostic testing. This month, I will answer some that are of great relevance to a retinal practice.

Q. Do you know if a scribe can legally draw, and color the drawing, for extended ophthalmoscopy in a patient chart or does it have to be drawn by the doctor?

A. No one other than the physician is permitted to draw and color the drawing required for billing extended ophthalmoscopy. Extended ophthalmoscopy is considered by Medicare to be a physician service; thus, it has to be performed by the physician to be eligible for payment.

There are no technical and professional components as with most other diagnostic tests. Be sure to complete the Interpretation and Report that is required as well.

There are many Medicare contractor/carrier Local Coverage Determinations for extended ophthalmoscopy—either active or retired—and it's best to read yours to assure compliance with regulations.

Q. Can you bill Medicare for a visual field in a patient with diabetes once a year if there are no ophthalmological findings? Can you do a visual field as a baseline testing with no medical findings? This would be considered a baseline test.

A. Every ophthalmologic diagnostic test, when ordered by a physician, must be ordered on the basis that it is medically necessary for the diagnosis/treatment of the conditions being considered. There must be either patient symptoms or clinical findings by the physician. In the absence of either of these two elements, there is no medical necessity that justifies the diagnostic test.

Diagnostic tests performed for screening purposes are not covered services by Medicare and some carriers have become strict on their interpretation of whether baseline tests are covered. Baseline studies still need to be medically necessary and based on clinical findings.

Visual fields performed in an asymptomatic patient with no clinical ophthalmological evidence of a disease process would not be covered. It cannot be performed as a baseline test.

Q. It was my understanding you had to have a medical finding to bill for testing, and that would include ophthalmoscopy. That if there are no findings/drawings, then you could not bill for photos/ophthalmoscopy. Correct?

A. It is possible to bill for an extended ophthalmoscopy on the basis of symptoms alone, such as flashes or floaters, as long as all of the chart documentation and interpretation requirements are met. Remember that extended ophthalmoscopy is a unilateral service, so in order to bill for each eye there must be symptoms or findings attributable to each eye.

Q. I received a request after an audit for overpayment of claims that exceeded $15,000 and covered several years. All of the claims are for fundus photos and OCTs done at the same visit and billed using modifier 59. My doctors routinely do OCT and fundus photos on patients as part of their standard of care and Medicare has paid in the past. Why the difference this time?

A. Unfortunately, this provider failed to be cognizant of Medicare's regulations regarding the National Correct Coding Initiative (NCCI) and the bundling edits. Be sure to read my previous 2011 articles.

Lessons to be learned:

► Just because Medicare pays a claim does not mean you coded correctly or that they will not audit you and ask for money back.
► Do not unbundle code edit pairs just because you can—the NCCI has become stricter in interpreting valid uses of modifier 59 for unbundling.
► “My docs routinely do OCT and fundus photos as their standard of care” negates Medicare's concept of medical necessity. Acceptable standards of care are not a physician's decision to make.
► There is no fighting this. You may be able to negotiate a lesser pay-back, but that is all. RP

CPT codes ©2011 American Medical Association

Riva Lee Asbell can be contacted at, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.