Innovative technology is advancing at a breakneck pace, and nowhere is that more apparent than in the realm of ophthalmic care. Every day there is news of new diagnostic and treatment devices, new procedures and new medications, to name only a few.

But therein lies the challenge from a coding and reimbursement perspective. There may be limitations that impede your ability to use new technologies in your clinical setting. Actually, I should be more specific: there may be limitations with a third party medical carrier when it comes to paying for this innovative care. Here are two pitfalls to look out for:

1. Who’s Footing the Bill. We have a hard reality to face, especially due to the changes in the medical insurance environment. Insurance premiums are increasing all across the country, causing deductibles to rise because the consumer dollar doesn’t go as far in buying coverage. That means that even for covered services, the patient will generally be the one responsible for the out-of-pocket cost until meeting their deductible. Even then, they may still encounter challenges with coverage and affordability.

Additionally, if something is not a covered service for a specific condition, the out-of-pocket expense for the test or procedure doesn’t apply to the deductible, making it even less affordable for most patients.

What’s an ABN? The ABN is a written notice you provide to a Medicare beneficiary before items or services are furnished when you believes Medicare will not pay for some or all of the items or services. The most current ABN form and instructions can be downloaded at www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html. In addition, there are four common modifiers that can be appended to CPT codes for the procedures that may be denied by the carrier. Depending on the service provided and the specific circumstances, the modifier can be either required by Medicare or voluntarily appended to the CPT code. While the ABN is a formal document required by Medicare, the concepts here often also apply to other commercial medical carriers as well.

2. What’s Covered, What’s Not. The realities of applying new technologies in practice may not always be what was represented by the sales person who sold you the equipment. Consider visual evoked potential (CPT code 95930), for example. This test helps detect glaucoma far earlier in the disease cycle—and I personally think our ability to deliver this test in a day-to-day clinical environment is incredible.^1,2 Unfortunately, there is a disconnect with insurance carrier policy for tests such as this. According to CMS, there are only three CMS carriers that have a coverage policy on 95930.³ And not a single one allows this test for any diagnosis related to glaucoma.^4-6

So what does that mean? Do you stop doing the test that assists in the early detection? Most likely not, but it does mean you should use an Advanced Beneficiary Notice of Noncoverage (ABN), knowing the patient will be bearing the cost.

This is a classic example of when technological innovation and third party coverage policy collide, and we will see more of this in the future, as coverage policies become based on outcomes and economics.
Innovations in technology that apply to direct patient care are integral to our ability to diagnose and treat patients effectively. Yet we must strike a balance in how we apply that technology based on the medical necessity for that specific patient and the cost the technology adds to the episode of care.

Patient contributions to their own health care costs are increasing—let’s make sure they spend their dollars wisely. 

Send questions and comments to ROcodingconnection@gmail.com.

1. Latina MA. Electrophysiology’s role in early detection of glaucoma. Ophthalmology Times. February 1, 2015. Available at http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/how-electrophysiology-plays-role-early-detection-glaucoma?. Accessed January 4, 2017. 2. Tsai JC. VEP technology for the detection of glaucomatous visual field loss. March 2009. Available at http://glaucomatoday.com/pdfs/GT0309_10.pdf. Accessed January 4, 2017. 3. Centers for Medicare and Medicaid Services (CMS). Local coverage determinations. Available at www.cms.gov/medicare-coverage-database/search/search-results.aspx?CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=95930. Accessed January 3, 2017. 4. CMS. Local coverage determination (LCD): neurophysiology evoked potentials (NEPs) (L34266). Available at www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34266. Accessed January 3, 2017. 5. CMS. Local coverage determination (LCD): neurophysiology evoked potentials (NEPs) (L34975). Available at www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34975. Accessed January 3, 2017. 6. CMS. Local coverage determination (LCD): Sensory evoked potentials & intraoperative neurophysiology monitoring (L34072). Available at www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34072. Accessed January 3, 2017.1.