ANNUAL DIAGNOSTIC TECHNOLOGY ISSUE

GET IN FRONT OF IT

A LOOK AT THE LATEST IMAGING DEVICES AND POINT-OF-CARE TESTING FOR THE ANTERIOR SEGMENT.

Whitney Hauser, O.D., Memphis, Tenn.

The world is transitioning quickly. From Pokémon to politics, sweeping changes are in the works, and this, of course, includes diagnostic technology. Knowing the appropriate diagnostic triggers is critical to capitalizing on new tech in your office.

Here, I discuss anterior segment diagnostic technology that may drive the ultimate diagnosis.

IMAGING

Anterior segment photography offers great utility. External photographs can be used in diagnosis, treatment and for assessing disease progression.

Six devices are available under the imaging umbrella:

• CellChek Specular Microscopes (SL and XL) (Konan Medical USA Inc). These non-contact devices reveal cell loss in the endothelial cell layer. (Cell loss may be set in motion by several factors, such as extended contact lens wear, corneal disease and ocular surgery.) The Specular microscopes offer objective data that can be monitored through time for anterior segment diseases, such as Fuchs' endothelial dystrophy. Additionally, the images provided by the units are valuable in patient education, as ocular conditions can often be difficult to explain to patients.

Diagnostic triggers: Endothelial defects, contact lens-related corneal changes, such as keratoconus and corneal crosslinking (CXL), pre- and post-operative cataract, Descemet stripping endothelial keratoplasty (DSEK), Descemet membrane endothelial keratoplasty (DMEK) and implantable collamer lens assessment.

Cost: Call (888) 310-0740 for a quote.

Billing: CPT code 92286. Historically, specular microscopy reimbursements have been higher than many other anterior segment CPTs, though they have decreased modestly through the past several years. Specular microscopy has a CMS 2016 National Average Maximum Allowable Reimbursement of $38.58. The code is bilateral. However, it may be used unilaterally if coded as 92286-52-RT or LT, and the fee would be reduced by half. Use of the code for specular microscopy is also limited by medical necessity for diagnoses, such as endothelial dystrophy (corneal guttata), corneal edema and other conditions. Additionally, the test is subject to the Multiple Procedure Payment Reduction rule if performed on the same day as any other special ophthalmic procedure Specular microscopy has a CMS 2016 National Average Maximum Allowable Reimbursement of $38.58. It is considered to be bilateral by definition, so if you are only performing this test on one eye, you would code 92286-52-RT or LT and reduce your usual fee by half). This code is also subject to National Coverage Decision 80.8 which limits the medical necessity of 92286 for very specific criteria for patients who have slit lamp evidence of endothelial dystrophy (cornea guttata), slit lamp evidence of corneal edema (unilateral or bilateral), are about to undergo a secondary intraocular lens implantation, have had previous intraocular surgery and require cataract surgery, are about to undergo a surgical procedure associated with a higher risk to corneal endothelium; i.e., phacoemulsification, or refractive surgery, with evidence of posterior polymorphous dystrophy of the cornea or irido-corneal-endothelium syndrome, or are about to be fitted with extended wear contact lenses after intraocular surgery. This test is subject to the Multiple Procedure Payment Reduction rule as well if performed on the same date of service as any other special ophthalmic procedure.

• Keratograph 5M (OCULUS, Inc.). This technology uses placido ring imaging to measure thousands of points over the entire cornea, while infrared placido disc illumination provides tear film analysis without triggering a reflex tear response. The Ketatograph 5M offers tear film-scan, non-invasive keratograph TBUT, tear meniscus height, lipid layer assessment and tear film dynamics. Further, the device offers the Jenvis Dry Eye Report, a patient education tool that compiles findings into one data sheet. Beyond assessing the tears and meibomian gland structure, the keratograph features keratometry, a soft contact lens oxygen transmissibility map and optional software that simulates static fluorescein patterns.

Diagnostic triggers:dry eye disease (DED) symptoms, corneal defects, decreased tear prism, meibomian gland dysfunction/inspissation and contact lens fitting.

Cost: Call (425) 670-9977 for a quote.

Billing: Images can be billed as CPT 92285 (external ocular photography), as no specific code exists for meibography, and CPT 92025 (corneal topography). The CMS 2016 National Average Maximum Allowable Reimbursement for 92285 is $20.68, and the for 92025 is $38.22. Keep in mind that 92285 is again considered to be a bilateral code so the same rules apply as described earlier, and 92025 is considered to be "unilateral or bilateral" so it would be billed the same whether the procedure was done on one or both eyes. Both tests are subject to the Multiple Procedure Payment Reduction rule as well.

• LipiView II and LipiScan (TearScience). LipiView II creates a high-definition image of the meibomian glands. It also offers lipid layer thickness and blink performance assessment. Data collected are presented on a large digital display as well as on an information sheet, allowing for patient education and documentation of findings.

LipiScan, which also offers high-definition meibomian gland images, images glands faster than its sibling and is smaller, making it easy to incorporate in offices that have limited space.

Once the glands are imaged by either system, a Meibomian Gland Evaluator (MGE), a tool that applies pressure, can be used to examine the glands from behind the slit lamp.

Diagnostic triggers: DED symptoms, vision fluctuations, meibomian gland dysfunction and inspissation.

Cost: Call (919) 459-4891 for a quote.

Billing: Lipiscan can be billed using 92285 for external ocular photography when imaging the Meibomian glands, while Lipiview should be billed using a HCPCS Level III code 0330T for tear film imaging. While there may be third party coverage for Lipiscan, Lipiview has no third party covereage and should be billed directly to the patient. Lipiview is defined as "unilateral or bilateral" so it is billed once whether performed on one eye or both.

• Pentacam (OCULUS). This technology incorporates rotating Scheimpflug imaging that captures 25,000 elevation points of the ocular surface in two seconds and generates a 3-D map based on the data collected. It is useful in the pre- and post-operative assessment of the anterior segment and can be used in the diagnosis and management of keratoconus patients. The device offers keratoconus detection maps and seven topometric indices (index of surface variance, index of vertical asymmetry, keratoconus index, central keratoconus index, index of height asymmetry, index of height decentration and index of minimum radius of curvature) to aid in the diagnosis and classification of keratoconus.

Diagnostic triggers: Keratoconus and CXL

Cost: Call (425) 670-9977 for a quote.

Billing: Coding for this particular test would most likely fall under Corneal Topography, CPT code 92025 and has a CMS 2016 National Average Maximum Allowable Reimbursement of $38.22 as described earlier.

• SPECTRALIS Anterior Segment Module (Heidelberg Engineering). This technology creates high-resolution images of the cornea and anterior chamber. The detailed images of the corneal layers are ideal for the diagnosis and monitoring of corneal dystrophies, such as Fuchs' endothelial dystrophy. It's also beneficial in identifying Descemet's detachment, corneal guttata and edema. The anterior chamber images are useful in assessing the depth of the angle closure and the angle structure for glaucoma patients.

Diagnostic triggers: Corneal dystrophy, glaucoma, tear film irregularities, pre/post-op refractive surgery and pre/post DSEK and DMEK.

Cost: Call (508) 530-7900 for a quote.

Billing: Anterior Segment OCT is properly defined by CPT code 92132 and currently has a CMS 2016 National Average Maximum Allowable Reimbursement of $35.00. It is defined as a "unilateral or bilateral" test and is also subject to the Multiple Procedure Payment Reduction rules. Special Note: While anterior segment OCT is a valuable clinical tool, the medical necessity for performing it and having it covered by a third party does not generally fall under the indications listed here and therefore is often non-covered and paid directly by the patient.

It’s worth noting that appropriate documentation must accompany photos for billing purposes (order for the test, date of testing, findings, diagnosis, impact on treatment and signature of the doctor). Also, multiple photographs may be taken in a single session, but may only be reported once. All tests described so far require an Interpretation and Report in order to be considered complete. Any test that is done where there is no Interpretation and Report in the medical record is not complete, nor billable to a carrier or the patient.

POINT-OF-CARE TESTING

With good reason, point-of-care testing is finding its way into more and more practices. These reliable diagnostic tests can quickly provide clinical direction. In order to perform and bill for these point of care tests, please make sure that your practice has the appropriate CLIA certification and designation. Tests designated with a -QW modifier have obtained their CLIA waiver and are safe to perform in a physician office. They also follow a different fee schedule that traditional testing and are subject to the Clinical Lab Fee Schedule.

Five point-of-care tests for the anterior segment are available:

• AdenoPlus (Rapid Pathogen Screening). This CLIA-waved test, comprised of a sterile sample collector stick, test cassette and buffer vial, quickly tests for all known serotypes of Adenovirus. The test boasts a 90% specificity and 96% sensitivity. Additionally, it provides a definitive answer to the common question, "Is this a viral red eye?" Receiving accurate test results can steer your treatment regimen in the right direction. Further, proper diagnosis may provide better containment for a contagious condition.

Diagnostic triggers: Red, watery eye(s), follicles present and history of systemic viral infection.

Cost: Call (844) 468-6777 for a quote.

Billing: CPT Code: 87809-QW- RT or LT(INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; ADENOVIRUS) The national average reimbursement for this test is $16.33 per eye.

• InflammaDry (Rapid Pathogen Screening). InflammaDry is comprised of a sterile sample collector stick, test cassette and buffer vial. It identifies the presence of MMP-9 (matrix metalloproteinase-9), a common inflammatory marker on the ocular surface in the tear film. Abnormal levels of MMP-9 correspond to DED and may affect corneal integrity and barrier function. A sample is acquired from the palpebral conjunctiva, with results obtained within 10 minutes. RPS reports InflammaDry has 85% specificity and 94% sensitivity.

Diagnostic triggers: DED symptoms, vision fluctuation, punctal plug preparation, conjunctivalchalsis.

Cost: Call (844) 468-6777 for a quote.

Billing: 83516-QW-RT or LT (IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD) The national average reimbursement for this test is $15.71 per eye

• Ocular Allergy Diagnostic System (OADS) (Bausch and Lomb). The OADS, formerly known as Doctor's Allergy Formula test, is an allergy diagnostic system useful in narrowing allergens that the patient should avoid. OADS is an allergy scratch test that requires no needles. The test pricks the skin with a plastic applicator. The applicator has a small amount of allergen and exposes the patient. Positive (allergic) responses are gauges on type of skin reaction. It takes approximately three minutes to administer the panel of 60 regionally specific allergens?) and 10 to 15 minutes for results.

Diagnostic triggers: Allergic conjunctivitis and allergic rhinitis.

Cost: Call (800) 828-9030 for a quote.

Billing: This test requires "breaking of the skin" and is generally not within the scope of an optometrist, so please check with your specific state board of optometry before performing this test in your practice. If deemed to be within the scope in your state, the CPT code used is 95004 (PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS). The CMS 2016 National Average Maximum Allowable Reimbursement is $6.76 per allergen. You would bill for the appropriate quantity depending on the number of allergens tested for. Generally a full panel would have a reimbursement value of approximately $405.60.

• Sjö Test (Bausch and Lomb). Sjögren's syndrome is often underdiagnosed or misdiagnosed. Specifically, it takes an average of 3.5 years for patients to receive an accurate diagnosis, according to the Sjögren's Syndrome Foundation. The Sjö test offers four traditional biomarkers and three propriety biomarkers that are useful in early diagnosis.

Diagnostic triggers: DED/dry mouth symptoms, fatigue, joint pain, decreased tear prism, decreased Schirmer's test and other autoimmune diagnoses, such as Lupus.

Cost: Call (855) 696-4269 for a quote.

Billing: The Sjö test is not one that has any reimbursement value within a medical practice as it does not fall under the CLIA waived testing requirements. Sjö requires a finger-stick to do a blood draw and this is generally out of the scope of practice of most optometrists. Please check with your state Board of Optometry before performing this test in your office. If allowed, CPT code 36416 (COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR STICK) but generally is not a separately reimbursable procedure. Please do not confuse 36416 with 36415 (COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE) which is separately billable and carries a reimbursement of $3.00

• TearLab Osmolarity System (TearLab). This technology measures the osmolarity of the tear film. A small sample (approximately 50nL) is acquired at the edge of the eyelid via test card and analyzed. Quantitative results are quickly obtained. TearLab reports an 89% predictive value for the test (the probability that individuals with a positive test do have DED.) Recent studies show that subjects with hyperosmolar tears have greater variability in their pre-operative cataract measurements (significantly keratometry and anterior corneal astigmatism readings), which could lead to unexpected refractive outcomes, according to the Journal of Refractive Surgery.

Diagnostic triggers: DED symptoms, vision fluctuations, pre/post-operative (cataract and refractive surgery), glaucoma and contact lens wear.

Cost: Call (855) 832-7522 for a quote.

Billing: 83861-QW-RT or LT (MICROFLUIDIC ANALYSIS UTILIZING AN INTEGRATED COLLECTION AND ANALYSIS DEVICE, TEAR OSMOLARITY ). The national average reimbursement for this test is $22.50 per eye.

WIN-WIN

Anterior segment testing has come a long way quickly, and innovation is not slowing down. While the clinical benefits to patient care are always first priority, practices can also benefit. Analysis of demographics and diagnoses codes has never been easier with the use of electronic health records. Knowing your patients, their conditions and your practice's goals can lead to wise purchases where everyone wins.OM

Special thanks to John Rumpakis, O.D., M.B.A., for his assistance. For full coding information, visit OM’s website.

DR. HAUSER provides clinical care for patients at TearWell: Advance Dry Eye Treatment Center and the Advanced Care and Ocular Disease Service at Southern College of Optometry. She is a consultant, speaker or board member for: Allergan, Akorn, Paragon Vision Sciences, BioTeck, BlephEx, TearScience, BioTissue, NovaBay, Lumenis, TearLab and Shire. Visit tinyurl.com/OMcomment to comment.