Q: Does coverage for diagnostic tests depend on who orders the test?
A: Yes. The Code of Federal Register clearly identifies where the order should originate.
As stated in 42 CFR §410.32 Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests: "Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary."
This issue is particularly relevant for mixed ophthalmic/optometric practices where patients first encounter the optometrist who triages patients for the surgeon. The optometrist certainly is able to diagnose a cataract, but ordering the A-scan or ocular coherence biometry is inappropriate, since the optometrist is unable to use the results to treat the patient. Other tests not appropriate for optometric order are fluorescein angiography, ICG angiography and, in some cases, glaucoma testing.
Q: When may an OD order glaucoma testing?
A: Most states have certification programs for optometrists to treat certain diseases, most notably glaucoma. If an optometrist is certified by his state, then ordering tests like visual fields, nerve fiber analysis and pachymetry is appropriate. If the optometrist is not therapeutically certified, the medical necessity for a test is in doubt.
Given this, all optometrists who are ordering these tests for treating glaucoma should be TPA-certified. Without TPA certification, the order for the test does not meet the requirement of the last sentence of 42 CFR§410.32: "Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary."
The distinction may lie in the doctor's differential diagnosis. For example: a patient presents to a non-therapeutically certified optometrist's office with a loss of peripheral vision. The optic nerves do not have an obvious glaucomatous appearance. The optometrist may order the test to determine which sub-specialist should be consulted.
If, however the patient has known glaucomatous findings and the intention is to forward the patient on to a glaucoma consultant, then a glaucoma test ordered by the optometrist is not medically necessary under the Medicare program because the ophthalmologist will use the results.
Q: If the diagnosis code for a given patient appears in the approved list of diagnoses in a Medicare policy, doesn't that automatically make the service covered by Medicare?
A: Not necessarily. At the root of diagnostic test coverage is the notion that the results will be used by the ordering physician to guide the treatment of the patient. The basis of this is found in the Social Security Act: §1862(a)(1) which states that "… 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 … ."
Some diagnostic tests are utilized to document the existence of a disease for medico-legal purposes, and the test is not used to diagnose or treat. In addition, the presence of the diagnosis is not a guarantee of coverage for repeat tests unless the diagnosis is changing or worsening and clinically warrants another test.
Q: Ophthalmic societies, Medicare and other third-party payers require external photography prior to blepharoplasty; is this a covered service?
A: Most of the time, no. The diagnosis of ptosis or dermatochalasis is made in the exam lane based on the patient's chief complaint, history of present illness and measurements. The photography is confirmatory in nature. Coverage for documentation may vary among commercial carriers, check your contract.
Photos used as a comparative study that are diagnostic, e.g., following changing characteristics of a lesion on the iris or on the lid, are covered. Photos are more accurate than drawings, with consistent scale and appearance. In the case of a ptosis repair, the photos may be covered if they are used to demonstrate Herring's Law with margin to reflex distance or a diurnal worsening of the ptotic condition later in the day.
Q: Taped and untaped perimetry is also required prior to blepharoplasty. Is this also considered documentation only?
A: No. The superior visual fields are diagnostic in nature. The taped visual field demonstrates a likely improvement to be gained with surgery. If the field does not improve while the lids are elevated, another disease may be causing the loss of superior visual field. The surgeon would use the field to either choose not to do the surgery and address the second disease, and/or explain to the patient that the blepharoplasty is cosmetic in nature. Many payers will cover only one perimetry (untaped) prior to blepharoplasty.
Ms. Kennedy is an associate consultant with the Corcoran Consulting Group. Contact her at 1 (800) 399-6565 or firstname.lastname@example.org.