Nothing can ruin a day faster than being notified you have been referred to an insurance carrier’s Special Investigations Unit because of overuse of special ophthalmic tests. This is particularly prevalent in glaucoma testing. Understanding a few key rules will help protect yourself, your patient and your practice.

Rule #1 – Medical Necessity Rules The Day

When ordering any special ophthalmic test you will submit to a third party for payment, clearly establish why you ordered the test and why it’s necessary in this patient’s case. Each test you order and perform must individually meet the requirement for medical necessity, which is based upon a clinical finding discovered during the patient exam. Your medical record must contain a written statement of this necessity.

Rule #2 – Individual I/R

Each ophthalmic test you perform requires its own interpretation and report (I/R) to be considered complete or billable. Each test and I/R must stand on its own, and be reflected in the medical record. An I/R should contain:

  • Clinical findings: pertinent findings regarding the test results
  • Reliability of the test
  • Comparative data: comparison to previous results, if applicable
  • Clinical management: how the results will affect management of the condition/disease, i.e.:
    • Change, increase or stop medication
    • Recommendation for surgery
    • Recommendation for further diagnostic testing
    • Referral to a specialist for additional treatment

Rule #3 – Choose Tests Wisely 

You should not apply a standard battery of tests on every glaucoma suspect patient. Choose your tests based upon their individual validity in that specific case, since you must demonstrate necessity for each test that you order and perform.

Rule #4 – Understand Your Provider Contracts

When you became a participating provider with a third party carrier, you received a document typically called a provider agreement—essentially a contract defining the parameters of what you can and cannot do with a patient with respect to covered services under that carrier’s plans. Policies and requirements are contained within this document or are tied to other references used by the carrier. Keep yourself up to date with current contract requirements, as they change frequently.

Rule #5 – Don’t Fudge A Diagnosis To Get Coverage

The number of times I am contacted by doctors asking what diagnosis to use to get a particular test paid for would amaze you. The ICD-10 is quite unforgiving—it is specific enough you can accurately report the diagnosis to the carrier, and it should support the necessity for the specific test in question. Take the time to learn the ICD rules—they are not just codes to get reimbursed.

Rule #6 – Love Your Sales Reps, Know Your Carrier Rules

Often, equipment manufacturers feel a test should be reimbursable for a specific disease state. They will have literature and studies that look impressive clinically, yet a carrier may not have a policy or reimburse you for the test. Manufacturers can make a clinical case to the carrier’s medical directors and demonstrate their technology’s efficacy in the diagnosis of disease, but they don’t always do this. It’s important to know your carriers’ specific policies.

Overtesting is a big concern today and is contributing to carriers’ rising costs.1 The CMS comparative billing reports highlight how carriers are looking at the frequency of testing and the combination of tests used on individual patients and in the aggregate within your practice. Outcome-based care rewards those who demonstrate the best outcomes in the most efficient manner. If you were paid a fixed fee per year for a patient with a specific diagnosis, would you still test to the same level, even without compensation for each test? The answer is important today, and will be for years to come.

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1. Weaver C, Jones C. Big driver of medicare spending: doctors doing more tests in their offices. The Wall Street Journal. August 9, 2016. Available at Accessed September 8, 2016.