I am often asked: “Are we doing all of our glaucoma testing at the proper intervals?” It’s a simple question, but the answer can have powerful implications.

Some ask because they want to maximize their possible income, while others ask more subtle questions. One of these questions is to find out if they perform diagnostic tests at an appropriate frequency from a payer perspective. Others also want to know how they compare to other ophthalmology or optometry offices or how one of their doctors compares to others but don’t know the exact numbers.

Answers to all of these questions can be valuable.

What you need

Let’s assume that you have well-documented medical necessity established in your medical records. The data you need comes from two main sources:

1. The claims you file to payers for tests and eye exams
2. Any payer-published norms.

Understand that the claims you file become raw data that payers use to analyze the care you provide — now with a serious focus on “cost vs. quality.” It’s also important to realize that you can use the same data — from your practice management and billing software — like the payers do.

Some examples

You should know whether a payer publishes a “standard” for expected frequency for each test (in this case, for glaucoma). Some tests, such as visual fields (VF) and OCT, have payer guidance while others may not.

Wisconsin Physicians Service Insurance Corporation, the Medicare contractor for Kansas, has one of the few current policies on VF. While they don’t speak to an exact number, their VF policy¹ notes that, “Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed ...” They also note that, “Those examinations found … at a frequency greater than is necessary … are not covered.”

Scanning computerized ophthalmic diagnostic imaging (SCODI, or OCT) of the optic nerve, CPT 92133, may also have some payer guidance. First Coast Service Options, the Medicare contractor for Florida, has some expected norms. They note the following in their current OCT policy²: “Because of the slow disease progression of patients with ‘suspect glaucoma’ or those with ‘mild’ glaucomatous damage … a frequency of >1/year is not expected.” They also note that “Patients with ‘moderate damage’ may be followed with scanning computerized ophthalmic diagnostic imaging and/or visual fields … If both … tests are used, only one of each test would be considered medically necessary ...”

So, unless you have a good reason to test a patient more often than the payer specifies (perhaps the disease is changing rapidly, which is unusual), there is a chance that insurance may not cover tests done more often than the above. In those cases, consider an Advance Beneficiary Notice (as noted in our May 2016 column: tinyurl.com/OPCodingMay16 ).

A look at frequency

To determine how your test frequency compares with others, you must know how many tests are billed to a payer. Medicare makes that data public, but private payers do not. You can sort the Medicare data by “ophthalmology” or “optometry” to get a general idea of how close you are to what a payer generally expects. Of course, if you are a retina practice, neither VF nor OCT of the nerve would be common at all. However, if you perform these tests fairly frequently because glaucoma is something your doctors manage, and you know that in 2015, Medicare Part B was billed by ophthalmologists about 11 times for every 100 billed eye exams for VF and nine times for OCT of the optic nerve, you have a point of reference.

You could also run a Medicare Part B “utilization” report by each doctor. You determine how many times you billed each of these tests as well as every time that doctor billed a “new” or “established” eye exam (excluding non-billed post-op visits) over the same time frame (say you choose six months). Divide the number of each test type by the sum of the new and established office visits to get your doctor’s percentage. For example, if you billed 200 VF tests and had 2,000 eye exams by the same doctor that same six months, your utilization is 10%.

If your percentage is significantly lower than the Medicare Part B benchmark, that doesn’t mean it’s wrong, but you should understand why. Is this a test that you should do more frequently to monitor disease properly? If it’s higher by a little or a lot, would your greater test frequency be likely to attract payer scrutiny? Could your documentation stand up to it? (In our March 2016 column, we noted the importance of an Interpretation as part of the documentation: tinyurl.com/OPCodingMar16 .)

Conclusion

While medical necessity for an individual patient “rules all” when deciding to perform diagnostic testing, it can be highly beneficial to know what coverage utilization limitations from payers are.

There are also significant benefits to benchmarking your office data to the published Medicare utilization norms. OP

REFERENCE:

1. Wisconsin Physicians Services, Inc. Visual Fields. LCD #L34615. Rev eff date 10/01/2016. http://ow.ly/O8F7307jI3M . Accessed Dec. 11, 2016.
2. First Coast Service Options (FCSO). Scanning Computerized Ophthalmic Diagnostic Imaging. LCD #L33751. Rev eff date 10/01/2016. http://ow.ly/fqPW307jIIW . Accessed Dec. 11, 2016.
3. Centers for Medicare & Medicaid (CMS). Medicare Provider Utilization and Payment Data: Physician and Other Supplier. http://ow.ly/uVYV-307jIO4 . Accessed Dec. 11, 2016.

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.