A question that we receive frequently at Corcoran Consulting Group is “How often can I do this test?” Some Medicare contractors and other payors place restrictions on how frequently they expect a test to be performed. Diagnostic testing is warranted when the information garnered from the eye exam is insufficient to adequately assess the patient’s disease.

In general, all diagnostic tests are reimbursed when medically indicated and properly documented. So, if a patient has a history of glaucoma (or another indicated condition) and the eye exam reveals unstable or worsening disease, then more extensive testing may be justified. That said, too-frequent testing can garner unwanted attention from Medicare and other payers, and could lead to an audit.

Here is a list of common diagnostic tests for glaucoma and their expected frequency, based on information published by the CMS and the Medicare Administrative Contractors (MAC).

FUNDUS PHOTOS

Many MACs have published policies, although not all. Check your MAC’s local coverage determination (LCD) for 92250 (fundus photography with interpretation and report) to see whether there are published frequency guidelines in your area.

Repeat fundus photography is necessitated by disease progression, the advent of new disease, or for planning for additional surgical treatment (eg, laser). Otherwise, repeated photos of the same, unchanged, condition are unwarranted.¹

CPT code 92250 and OCT 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) and 92134 (scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina) are bundled and should not be billed on the same day.

OCT

CPT code 92133 is generally allowed 1 to 2 times per year for glaucomatous patients, usually for early or moderate disease. The code 92134 is allowed more often, typically up to four times per year.² Clear documentation of the reason for testing is always required.

PACHYMETRY

Many MACs have published LCD policies for corneal pachymetry by ultrasound (which is CPT code 76514). Most published LCDs indicate that corneal pachymetry for glaucoma is covered once in a patient’s lifetime unless there has been interval corneal trauma or surgery.

VISUAL FIELDS

Many MACs have published guidelines for repeated testing. Typically, one field per year is warranted for borderline or controlled glaucoma, twice a year for uncontrolled glaucoma, and three times a year for extreme cases, such as one-eyed patients or when the disease is progressing rapidly.

The CPT codes associated with these tests are 92081, 92082, and 92083; the code used depends on the complexity and detail of the perimetry testing.³

NO SINGLE ANSWER

The answer to the seemingly simple question of how frequently physicians can expect to receive reimbursement for repeat diagnostic testing for glaucoma is, “it depends.” No single answer suffices. Physicians who consider the factors discussed in this article may develop a richer and more nuanced appreciation for how and when they should repeat diagnostic testing.

Come back next month when we talk about reimbursing for standing orders for diagnostic testing. OM

REFERENCES

1. Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography). Centers for Medicare & Medicaid Services. http://bit.ly/3YRMoc8 . Accessed Jan. 12, 2023.
2. Medicare Reimbursement for SCODI of the Posterior Segment. Corcoran Consulting Group. https://bit.ly/3k2ZaFF . Accessed Jan. 12, 2023
3. Medicare Reimbursement for Visual Field Test (Oculus). Corcoran Consulting Group. www.corcoranccg.com/products/faqs/visual-field-testing-oculus/ . Accessed Jan. 12, 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.