Coverage for diagnostic tests is questionable, and claims for reimbursement are often denied if pathology is not found and there is no diagnosis. In clinical practice, this occurs when diagnostic tests are interpreted as normal. However, a normal finding can mean more than one thing, which might change reimbursement depending on how it is charted, coded, and billed. Under the most difficult circumstance, the diagnostic test is ordered for a credible reason, but the findings of the test are normal, so the payer will not cover it due to a restrictive policy. Who pays for the test? It depends on how the test is ordered and documented in the medical record.
General Principles of Coverage
Payment for medical services relies on the straightforward concept of evaluation and management of illness or injury. Within the Medicare program, the basic principle of covered, medically necessary services is the foundation of reimbursement, and is succinctly stated in the Medicare law1 unless explicitly covered in another part of the statute: “no payment may be made under part A or part B for any expenses incurred for items or services … which … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member … [or] which are not reasonable and necessary for the prevention of illness.” In billing, this principle entails finding an ICD-10 code for a disease, abnormality, or injury that is paired with a CPT code for a procedure or HCPCS code for a product. It is axiomatic that reimbursement will not be forthcoming without justification of a medically necessary service.
In cases where a diagnostic test is performed and no disease process is identified as a result of the test, and the ophthalmologist or optometrist writes “normal” in the interpretation and report, we probably will not be reimbursed for the test unless there are mitigating reasons that warrant the service. Usually, the mitigating reason(s) are symptoms, suggestive medical history, genetic predisposition, or the clinician’s suspicion following conversation with the patient. Where those reasons are insufficient for reimbursement, we typically find that the payer’s coverage rules are narrowly defined or preclude the use of vague and ambiguous ICD-10 codes such as: H53.8 (blur), H57.1 (eye pain), H53.14 (visual discomfort or photophobia), H53.15 (visual distortions), H53.9 (visual disturbances), Z04.x (encounter for examination and observation), Z05.x (suspected conditions ruled out), Z13.1 (diabetic screening), Z13.5 (screening for eye), Z20.828 (suspected exposure to viral communicable disease), Z82.x (family history of disability), and Z83.x (family history of disease). Billers appreciate that some ICD-10 codes are stronger than others.
When Diagnostic Tests Are Indicated
Tests may be ordered for a host of reasons, including the following:
- To elucidate patient symptoms,
- To explore clinical exam findings in greater detail, and
- To monitor progression of known disease.
Ophthalmologists and optometrists assume that these reasons are sufficient justification for reimbursement, and they frequently are. Yet, limitations in coverage policies might cause a hiccup and no payment. As noted above, symptoms are not always listed as covered indications in third-party payer coverage policies. For example, National Government Services does not cover scanning computerized ophthalmic diagnostic imaging (SCODI) for H53.14 (visual discomfort or photophobia), H53.8 (blur), H57.1 (eye pain), Z13.1 (diabetic screening), Z13.5 (screening for eye), Z82.x (family history of disability), and Z83.x (family history of disease).2
Suspected Condition Not Found
During an eye exam, a doctor observes elevated cup-to-disk ratios with the direct ophthalmoscope that indicates enlarged cups. SCODI of the optic nerve is ordered and performed. The interpretation and report states “normal optic discs.” With the benefit of a detailed image of the optic nerve, no abnormality is detected, and no disease identified. The suspected glaucomatous condition (H40 to H42) was not found. This test (CPT 92133) is not covered for Z04.x (encounter for examination and observation) or Z05.x (suspected conditions ruled out). Who pays for the service? The answer depends on how you ordered the test.
If the examining physician counseled the patient that they suspected glaucoma, but that SCODI of the optic nerve (and perhaps other diagnostic tests as well) would help confirm or refute that assessment, and that insurance coverage only applied to a positive outcome and the negative outcome was the patient’s financial responsibility subject to a signature on a written financial waiver or Advance Beneficiary Notice (ABN) prior to testing, then it’s clear that the beneficiary must pay for the service. How many ophthalmologists and optometrists take this route? Commonly, there is no discussion with the patient; the physician directs the technician to immediately perform the test. If the result is positive, the test is billed to the patient’s insurance. If the result is negative, the test is not billed to anyone.
Advance Beneficiary Notices in the Real World
An ABN of noncoverage is a written notice given to a Medicare beneficiary when the provider believes that Medicare will probably not pay for some or all of the items or services. Get a signed ABN before providing the item or service, so the beneficiary is financially responsible for noncovered items and services.
In theory, this sounds like a viable method to ensure payment. As a practical matter, the physician’s time is more valuable than the test reimbursement. Also, a discussion of financial waivers as a precondition for testing is distasteful to patients and gives the wrong impression about physician motivation. It might even be misconstrued as a failure to provide appropriate care, even if reimbursement was not assured.
Importance of Chart Documentation
Just because the findings of a test are “normal” does not necessarily mean there is no disease. For instance, visual field defects do not appear in perimetry until there is substantial damage to the optic nerve from glaucoma. So, a patient with open-angle glaucoma might have a “normal” visual field. The chart note should state that no visual field defect or scotoma was found; however, the diagnosis is still open-angle glaucoma. Simply writing the word “normal” in the medical record is potentially misleading and detrimental to reimbursement.
The same patient with a history of open-angle glaucoma is examined with a goniolens as recommended in the American Academy of Ophthalmology Preferred Practice Pattern for Open-Angle Glaucoma.3 You observe open angles without narrowing, hyperpigmentation, synechiae or obstruction; the angles are “normal.” The absence of narrow angles is instructive, yet it doesn’t mean that there is no glaucoma. Charting “open angles” is preferred to the word “normal,” which connotes healthy eyes.
Here’s another example. A patient with dry eye disease (H40.12x) has been successfully treated with a combination of artificial tears and punctal occlusion of the lower puncta. On re-evaluation with tear osmolarity testing, the results of the test are “normal” — 298 mOsms/L — in both eyes. These results indicate that the chronic condition is not progressing, and the treatment is working; however, the patient still has dry eye disease. Writing “normal” in the medical record could imply that the patient does not have dry eye disease. Instead, the measurement of tear osmolarity is within normal limits (WNL), but the dry eye disease is not cured.
Let’s consider this case. A new patient presents for an eye exam on the recommendation of her primary care physician because the patient is newly diagnosed with type II diabetes mellitus. A careful fundus examination finds a “normal” fundus without any hemorrhages, microaneurysms, or other indications of diabetic retinopathy. You order fundus photography to establish a baseline, and the interpretation and report states only “type II DM.” Payers do not treat a claim for fundus photography in universally the same way. Palmetto GBA and National Government Services allow claims for fundus photography for a diagnosis of E11.9 (diabetes without ocular manifestations).4,5 First Coast Service Options (FCSO) excludes this diagnosis from coverage for fundus photography.6
Conclusion
Reimbursement for a diagnostic test depends on having a good reason for doing it. In most cases, that means finding pathology or abnormality. Yet, not all tests find something wrong, because a foreordained outcome would nullify any medical reason for doing the test in the first place. Some tests find nothing. Clinicians often write “normal” on the test report in such cases. That word can have several meanings. It doesn’t necessarily mean the absence of disease, so amplifying the chart note is very useful and might support reimbursement. From a payer’s perspective, “normal” hints at a reason not to pay for the test. GP
References
- 42 USC 1395y exclusions from coverage and Medicare as secondary payer. Accessed July 20, 2022. https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
- National Government Services Medicare Part B, A56537, scanning computerized diagnostic imaging. Accessed July 20, 2022. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56537&ver=23
- American Academy of Ophthalmology. Primary open-angle glaucoma preferred practice pattern. Accessed July 20, 2022. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2820%2931024-1
- Palmetto GBA Medicare Part B, A53060, ophthalmology: extended ophthalmoscopy and fundus photography. Accessed July 19, 2022. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53060&ver=29
- National Government Services Medicare Part B, A56726, ophthalmology: posterior segment imaging. Accessed July 19, 2022. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56726&ver=23
- First Coast Service Options Medicare Part B, A57075, Fundus Photography. https://medicare.fcso.com/
