As a follow-up to last month’s article on how often an optometrist can bill diagnostic tests for reimbursement, this month we discuss reimbursement for screening tests. Screenings are commonly used prior to an eye exam. While they can aid the optometrist in identifying ocular disease early, they can also cause reimbursement complications, as we will discuss below.

WHAT IS AND IS NOT REIMBURSED

As a rule, Medicare and most other payors do not cover routine screenings. CMS states, “the physician must clearly document, in the medical record, his or her intent that the test be performed.”¹ To avoid this difficulty with reimbursement, physicians should examine the patient first and then determine which tests, if any, are necessary before ordering them.

Alternately, and less commonly, a physician may formulate an order for testing before any examination. The order would be based on information about an individual patient’s unique illness, injury, or medical condition provided by another physician, health care professional, or the patient themselves.

Here are a few examples:

• An optometrist receives a copy of the chart notes from a referring doctor who asks for a consultation and, after reviewing the chart, the optometrist orders a diagnostic test to be administered upon the patient’s arrival.
• Your technician takes a history from a new patient and finds something concerning. The technician brings the information to you, and you order an immediate diagnostic test based on it.
• A patient calls and speaks to the physician who then orders a diagnostic test based on the phone call.

In all of the above examples, the physician orders the test for a specific medical problem and uses the results in the management of that problem.

Finding disease on a screening test does not confer reimbursement eligibility. It frequently leads to additional evaluation and management services, albeit not necessarily on the same day. Re-doing a visual field (VF) test later the same day as the screening image (or on another day close in time to the initial test) does not provide coverage for either VF test.

SCREENING BASICS

According to Medicare, screening occurs when the test is performed for one or more of the following reasons:²

• Part of a wellness program to check for a disease that may otherwise go undetected.
• Not required by medical necessity; the reason for doing them is optional.
• Taken before the patient is examined by the eye care provider.
• Done for all patients as a matter of course, unless they decline.

If a screening service is not covered by a payor and must be paid for out-of-pocket by the patient, the patient must be given the opportunity to choose between an exam with or without the screening tests. Practices should use a financial waiver to document the beneficiary’s acceptance of financial responsibility for the screening service.

KNOW THE LIMITS

While screenings can be helpful, ODs should be aware of the limitations they have for reimbursement. It is important for a provider to recognize the circumstances under which certain screenings can be ordered, and how those circumstances affect coding. OM

REFERENCES

1. Orders for Diagnostic Testing. Palmetto GBA. https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/9UWS234470~Specialties~Radiology Published May 29, 2020. Last accessed 1/9/2023
2. Screening Services – JE Part B. Noridian Healthcare Solutions. https://med.noridianmedicare.com/web/jeb/specialties/lab/screening-services Last Updated Dec. 9, 2022. Accessed Jan. 1, 2023.

BRANDY H. SPERRY is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext. 238.