You want to do right by your patients and offer
them the most comprehensive care your ophthalmology practice can serve up. That
includes providing anterior segment imaging. However, there are a lot of costs
involved with that service, and you’ve heard how Medicare hasn’t always
reimbursed your colleagues.
It’s true. Medicare reimbursement for anterior
segment imaging is an iffy thing—sometimes they do and sometimes they don’t.
But you can increase your chances of
Medicare reimbursement for anterior segment imaging, and beat the odds. It’s
all in what you do, how you do it, and how you document what you’ve done.
Medicare reimbursement isn’t a matter of voodoo,
winning the lottery, or having a good hair day. No, Medicare reimbursement for
anterior segment imaging greatly depends on the reason you want to perform anterior segment imaging. There are only
three acceptable reasons for doing anterior segment imaging as far as Medicare
reimbursement is concerned, and they are:
- 1.The images obtained provide additional
information that can’t be obtained in any other way during the examination.
- 2.The images are taken to assess a
patient’s disease progress.
- 3.The images are taken to aid in the
diagnosis and treatment of a condition.
That’s it. We’ll look at each one in turn in more
detail in a moment, but just know that if you perform anterior segment imaging
on a patient for any other reason, Medicare is going to deny your claim and
refuse reimbursement. So, with that in mind, let’s look at the ways in which
you can offer anterior segment imaging to your patients and still receive
Medicare reimbursement every time you make a claim.
1: Images Provide Additional Information
If you can prove that you can’t properly gain
vital information about a patient’s eye health or vision without using anterior
segment imaging, you will better your chances of a Medicare reimbursement for
the service. Some ideas to do this include:
– If the patient has a history of glaucoma, or you suspect glaucoma, you can
use your anterior segment imaging to determine the presence or absence of the
condition. Most Medicare claims for anterior segment imaging for glaucoma state
that the imaging was done as part of a routine exam. The operative word that
gets those claims denied is “routine.” If you can get the information from
other sources, or don’t necessarily need to perform imaging on a patient but do
it anyway routinely, you can kiss your Medicare reimbursement goodbye. However,
citing a possible diagnosis of glaucoma and using your anterior segment imaging
to confirm or deny, will likely better your odds at reimbursement.
– Most anterior segment imaging cameras can take images from multiple angles,
aiding in the diagnosis of kerataconus and making it easier to spot early on, as
it is relatively symptom-free. Anterior segment imaging as a screening for
kerataconus is a must for anyone facing refractive surgery.
surgery – You should know that you can’t always trust the
pre-op test results. Go with anterior segment imaging before you perform or
refer any patient for refractive surgery. Also, use your anterior segment
imaging to monitor post-op progress and recovery.
2: Images to Assess Disease Progress
Using anterior segment imaging to monitor a
patient’s disease is one of the easiest ways to receive Medicare reimbursement
for the service. A patient with a documented case of glaucoma or kerataconus or
another condition almost always automatically qualifies for Medicare
reimbursement. As the Boomer generation ages, and age-related eye conditions
such as glaucoma and diabetic retinopathy become more common among them, your
patients will appreciate that you can easily monitor their disease progress and
take appropriate steps to help save their vision.
3: Images to Diagnose or Aid in Diagnosis
This one may be the easiest to “pull off” as far
as Medicare reimbursement is concerned. If you can claim that without the
anterior segment imaging you can’t rule out a serious condition, or can’t
quantitatively affirm a suspicious diagnosis, you’ll stand a good chance at
reimbursement for the service. So, what condition could your patient possibly
have or not have that would warrant a series of anterior segment images? You
may have to be clever and imaginative, but if you truly feel a patient would
benefit from anterior segment imaging but have no real grounds for performing
the service, claiming a potential serious diagnosis, or a suspected condition,
may just do the trick.
Medicare Won’t Reimburse
We’ve already touched on the fact that Medicare
reimbursement for anterior segment imaging is virtually impossible if the
imaging is part of a “routine” exam or visit. That’s because not everyone may
need the service, at least in the eyes of Medicare. There’s another case that
will be an automatic denial of your patient’s claim, and that’s if the anterior
segment imaging is performed merely to document the presence of disease. If you
are not actively monitoring a disease progression or the effectiveness of a
treatment, you will not be reimbursed.
You Need For Making a Claim
The photos or images taken during anterior segment
imaging alone are not enough to justify your claim. You’ll also need to provide
- An order for the images with stated
medical rationale for performing them
- The date of the test
- The reliability of the testing, as in
- The test’s findings
- The diagnosis, if any, based on the
- The impact of said diagnosis on
treatment and prognosis
- The signature of the ophthalmologist
or other physician performing the imaging test
Accompanying your claim with all of the above will
give Medicare enough to determine whether or not reimbursement is justified.
Guarantees on Medicare Reimbursement
While it’s true that Medicare reimbursement is
made in cases claiming the above three circumstances, there is never a
guarantee that you will receive reimbursement, regardless of justification,
documentation, or rationale behind the imaging. There just isn’t. And some
practitioners will feel bad about any of subterfuge they may feel they have to do
in order to both provide their patients the care and services they need and
receive Medicare reimbursement for those services and care. It’s really a matter
of which is more important—the patient’s vision, or your Medicare
reimbursement. And sadly, that’s often a choice that has to be made.