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FOLLOW-UP CARE AND IMAGING

POST-CATARACT SURGERY CARE, FUNDUS IMAGES IN DIABETICS AND DEFECTS IN OCT

JOHN RUMPAKIS, O.D., M.B.A.

Q: IF A PATIENT HAS CATARACT SURGERY AND HE OR SHE RETURNS TO MY CARE FOR HIS OR HER ANNUAL EXAM, DOES MEDICARE PAY FOR IT ONCE A YEAR TO SIMPLY CHECK THE IMPLANTS, OR IS IT CONSIDERED TO BE A ROUTINE EXAM?

A: Medicare pays for professional services related to complaints or symptoms of an eye disease or injury. Obviously, the follow-up of a post-cataract surgery patient is a common occurrence within an optometric practice. Since Oct. 1, most have experienced denials for a 920X4 combined with the Z96.1 (formerly V43.1). Why? Medicare doesn’t — and never has — paid for “an annual exam.” They do pay for services and procedures that are medically necessary and provided at an appropriate interval based on the needs of the individual patient. If a patient has an IOL and has completed a successful post-operative period (currently 90 days), what are you having the patient back for? As an analogy, if I were an orthopedic surgeon and completed a knee replacement on a Medicare patient, would I need a comprehensive exam once a year on an asymptomatic patient just to make sure that everything was OK? No. The same could be said for an IOL. If the patient has symptoms or has noticed any changes in their vision, then an appropriate level of examination and a refraction would be indicated, but an “annual exam” just to check the implant would most likely be considered to be routine and thus non-covered.

Q: CAN I DO A FUNDUS PICTURE ON ALL DIABETIC PATIENTS AND BILL THE MEDICAL INSURANCE COMPANY?

A: Unfortunately not. Fundus photography, like any special ophthalmic procedure that you order or perform, must be based upon medical necessity. The meaning of medical necessity means that the medical record must clearly demonstrate that the service, procedure, or test ordered & performed was absolutely necessary in order to diagnose, treat, or monitor the treatment of the patient’s condition. So if a patient is diabetic, but they have no retinopathy, there would not be a reason to order or perform a fundus photograph and bill the medical carrier for it.

Based on ICD-10, most likely you would be coding it as E10.9, Type I diabetes without complications, or E11.9, Type II diabetes without complications. The wording “without complications” means just that; there would be nothing present to photograph.

As an alternative to your question, if your retinal camera or imaging device has a screening mode, you can offer the patient the option of taking a screening retinal image for an out-of-pocket cost. You would use HCPC code S9986, not medically necessary service. According to carrier guidelines, this photo has to be different than the one you would take to code for fundus photography. It is not just the Interpretation & Report that creates the difference between the two images.

Q: I TYPICALLY OFFER OPTIC NERVE AND MACULA OCT AS OPTIONAL OUT-OF-POCKET TESTS. IF THERE ARE DEFECTS, IS IT MEDICALLY NECESSARY TO ORDER A GLAUCOMA WORKUP?

A: Straight answer, I’m not sure. If pathology is consistent with a glaucoma patient, then I think it appropriate to follow-up with an appropriate level of testing that would allow you to make the most accurate diagnosis in the most efficient fashion. I assume your OCT has a screening mode, which produces images different than those coded OCT (92132, 92133, and 92134). If you are not using a screening mode, then there would be no reason to repeat the OCT and bill it to the insurance carrier. You could certainly perform other tests that are medically necessary to assess the patient and create a medically sound plan for him or her. OM

Questions are based on reader responses to an Optometric Management online survey, which closed on Dec. 20.

DR. RUMPAKIS is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. Email him at John@PRMI.com, or visit tinyurl.com/OMcomment to comment on this article.