Beat the Odds: Increase Your Chances of Medicare Reimbursement for Anterior Segment Imaging

by | Tuesday, October 28, 2014 | 0 comment(s)

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.

Reason 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:

  • Glaucoma – 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.
  • Kerataconus – 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.
  • Refractive 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.

Reason 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.

Reason 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.

What 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.

What 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 the following:

  • An order for the images with stated medical rationale for performing them
  • The date of the test
  • The reliability of the testing, as in patient cooperation
  • The test’s findings
  • The diagnosis, if any, based on the test’s findings
  • 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.

No 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.


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