Coverage for diagnostic tests is questionable. Claims are often denied if pathology is not found and the physician offers no diagnosis. Let’s review what you need to know in order to file a claim successfully.

Q. When is a claim for a diagnostic test covered?

A. In general, payment for medical services relies on the straightforward concept of evaluation and management of illness or injury. Within the Medicare program, the basic principle of covered, medically necessary services is the foundation of reimbursement, and is succinctly stated in the Medicare law unless explicitly addressed elsewhere: “… no payment may be made … for any expenses incurred for items or services … which … are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member ….”

You will not be paid without justification of a medically necessary service. You must find an ICD-10 code for a disease, abnormality, or injury that is paired with a CPT code. Sometimes signs and symptoms are acceptable diagnosis codes, but usually payers’ coverage rules are more narrowly defined. Billers appreciate that some ICD-10 codes are more acceptable than others.

Q. When are tests indicated?

A. Tests may be ordered for many reasons, including the following:

• To elucidate patient symptoms,
• To explore clinical exam findings in greater detail, and
• To monitor progression of known disease.

Ophthalmologists assume that these reasons are sufficient justification for reimbursement, and they frequently are — but not always.

Q. What happens when the suspected condition is not found?

A. Here’s an example:

During an exam, you observe what may be cystoid macular edema in the right eye with the direct ophthalmoscope. Optical coherence tomography of the retina is ordered and performed. With the benefit of a cross-sectional detailed image of the macula, no abnormality is detected, and no disease is identified. The interpretation and report states “normal retina.” The suspected CME of the right eye (H35.351) was not found, and there was no prior cataract surgery so H59.031 (CME following cataract surgery) is also not applicable. This test (CPT 92134) is not covered for Z04.x (encounter for examination and observation) or Z05.x (suspected conditions ruled out).

So, who pays for the service? The answer depends on how you ordered the test.

The beneficiary must pay for the service under the following conditions:

• You counseled the patient that you suspect CME, OD, but that optical coherence tomography of the macula (and perhaps other diagnostic tests) would help confirm or refute that assessment;
• You further explained that insurance coverage only applied to a positive outcome (disease is present) and the negative outcome (no disease) was the patient’s financial responsibility subject to a signature on a written financial waiver or Advance Beneficiary Notice of Noncoverage (ABN); and
• You did this prior to testing.

Now, how many ophthalmologists take this route? In the real world, there is usually no discussion with the patient. Instead, the physician directs the technician to immediately perform the test. If the result is positive, the test is billed to the patient’s insurance. If the result is negative, the test is not billed to anyone.

Q. How do we document medical necessity for a test when the results are normal?

A. Just because the findings of a test are “normal” doesn’t necessarily mean there is no disease. Let’s consider another case. A new patient presents for an eye exam on the recommendation of her primary care provider because the patient is newly diagnosed with type II diabetes mellitus. A careful fundus examination finds a “normal” fundus without any hemorrhages, microaneurysms, or other indications of diabetic retinopathy. You order fundus photography to establish a baseline, and the interpretation and report states only “type II DM.” You obviously had a reason to order the test.

Payers do not treat a claim for fundus photography in universally the same way. Some allow claims for fundus photography for a diagnosis of E11.9 (diabetes without ocular manifestations), while others do not. Check your payers’ policies.

Q. What is the take-away?

A. Reimbursement for a diagnostic test depends on having a good reason for doing it. In most cases, that means finding pathology or abnormality. Yet not all tests find something wrong because a foreordained outcome would nullify any medical reason for doing the test in the first place. Some tests find nothing. Clinicians often write “normal” on the test report in such cases.

That word can have several meanings. “Normal” doesn’t necessarily mean the absence of disease, so amplifying the chart note is very useful and might support reimbursement. But, from a payer’s perspective, “normal” hints at a reason not to pay for the test. RP