Incorporating new technology into your practice is always an exciting event. Being able to harness this newfound clinical assistant allows you to continue to provide care at the highest level. However, incorporating new technology isn’t always a slam-dunk; each CPT code used to describe the testing performed has specific rules, regulations and guidelines that you have to follow before the test can be ordered, performed and billed. You can’t simply do the test because you have a covered diagnosis or the procedure is covered by a plan.

Medical Necessity vs. Covered Procedure
Somewhere between “this is how you turn it on” and “this is a list of covered diagnoses you can bill for” lies the professional responsibility of establishing medical necessity for ordering tests or performing procedures. You must demonstrate in the medical record that the procedure or test is needed to diagnose, follow a diagnosis, treat or monitor treatment. You must tell the story of the patient encounter, including your reasoning for what you are doing. If you feel that a procedure is necessary to aid you in a patient’s diagnosis or treatment, then tell the record why you feel that way. It’s your only defense in a post-payment review process. 

With ICD-10, you are going to have to know whether the procedure is bilateral or unilateral, whether it requires a modifier to change it and whether your patient’s specific presentation requires the test in one or both eyes. This, of course, will have to support the specific laterality of the ICD-10 codes. 

A whole host of patient symptoms appear in lists of covered diagnoses for a specific procedure. However, the ICD is quite specific in what you can—and can’t—use as a billable diagnosis. Current ICD rules indicate that codes describing symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes only when a provider has not established a related definitive diagnosis. You cannot simply perform any test you want just because the symptom is covered; you must base your decision on the actual diagnosis and medical necessity of that individual patient. Remember, HIPAA requires you to follow the rules of the ICD, so you are legally bound to do so.

Interpretation and Report
An interpretation and report (I&R) needs to be clearly identified within your medical record for the specific test with which it is associated. Each test you perform requires its own I&R because each must have proper medical necessity established in the medical record if a third-party carrier is going to pay for it. 

If you have a specific reason why you believe a test may be denied, use an advance beneficiary notice and the appropriate modifier accordingly. 

Here are the typical items you should include in an I&R:

• Clinical findings, which are the pertinent data of the test results.
• Your interpretation of those findings.
• Comparative data to previous test results (if applicable).
• Clinical management, which explains how the test results will affect the management of the condition/disease. Examples include: change/increase/stop medication; recommend surgery or further diagnostic testing; refer to a specialist/subspecialist for additional treatment; or return for additional office visits for treatment or monitoring.

Simply performing the technical component of the test is not enough, nor is initialing the test to show that you’ve looked at it. When a carrier finds that an I&R hasn’t been completed, the entire test is deemed invalid and financial recoupment is for the test in total. If you perform only the technical component without completing the I&R, the test isn’t complete in the eyes of the insurer and the entire payment amount, not just the professional component, is recouped by the carrier.

Diagnostic testing is more common in today’s optometry practice than ever, and will continue to grow. Fulfilling the diagnostic test requirements by appropriately completing an I&R for each test performed will not only benefit your patient, but will also reduce your risk.

Send questions and comments to ROcodingconnection@gmail.com.