One of the most significant shifts in diagnostic skills and techniques—this issue’s focus—is the fact that many of the diagnostic skills we employ today depend on not just clinical techniques, but on technology. 

Most ophthalmic technology developed within the last decade is used for special ophthalmic testing; subsequently, the CPT established a proper definition and foundation for them, and we must follow specific rules when performing, recording and coding for them. Special ophthalmic tests are contained in a separate section of the CPT, with the following preamble:1

“Describes services in which a special evaluation of the part of the visual system is made, which goes beyond the services included under general ophthalmological services or in which special treatment is given.

Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services.”

Any test defined as a separate and distinct procedure by virtue of having its own CPT code is not part of an office visit, whether it’s a 920XX or 992XX code. They can be ordered and performed on the same date of service as the office visit, as long as they are performed in accordance with CMS’ National Correct Coding Initiative Edits and meet all requirements specific to your geographic location for medical necessity. 

Most audit failures for special ophthalmic procedures are generated by not providing adequate or appropriate medical necessity for performing the test in the medical record and simply testing because you want to do the test or are testing to provide a baseline of normalcy.

Getting the Codes Right

Special ophthalmic codes are composed of two distinct components: the professional and technical. If you are performing both the technical and professional component in your practice, you will not separate the code into individual components, but will report the code in its entirety. The two modifiers that separate a code are:

 -26 Professional Component. Use this modifier when the physician component is reported separately.2

• -TC Technical Component. This includes the equipment and technician performing the test.2 Billing for staff time and the test is improper and would raise a red flag.

When ordering special ophthalmic tests, in order to meet the coding requirements, you must meet the medical necessity for the tests. You cannot perform a test, code it, bill for it and get paid just because you want to. It has to be necessary to do so, and you must demonstrate in the medical record that it had a role in managing the patient outcome.

Screening vs. Ordered Tests

Many of the new technologies today are used routinely on patients as screening tests. However, this practice is not always appropriate. With routine fundus imaging, for example, many are inappropriately using a screening image as a substitute for dilating the patient. I am not aware of any circumstance where a routine retina screening image is a legal substitute for dilating the patient. 

If you are performing screening tests on patients, the appropriate code to use is S9986 (not a medically necessary service) and you must inform patients that the test is not medically necessary. They should also understand they are financially responsible for the test in all circumstances and that the test should be performed before they see you.

Watch Your Back

With the recent release of the Comparative Billing Reports in October 2015 and the implementation of ICD-10, it is much easier for carriers to analyze your practice patterns. Frequency of testing and correlations with highly specific ICD-10 diagnoses help carriers flag individuals who are causing potential waste and abuse, or worse yet: fraud. Technology is a wonderful tool and can certainly add to our diagnostic and clinical skills—use it appropriately and it’s great for both patient and practice; use it to replace rather than augment your clinical skills and you may find yourself in a more challenging situation. 

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1. American Medical Association. CPT Professional Edition. American Medical; 2016:591.

2. American Medical Association. CPT Professional Edition. American Medical; 2016:Appendix A.