Article

Coding & Reimbursement

The skinny on screening tests

Screening tests can be a great adjunct to any practice, but they must be done correctly.

Q. What are screening tests?

A. As a general rule, most payers, including Medicare, do not cover tests not ordered by a physician as a part of the medical care of a patient. These uncovered tests are considered “screening” or preventive medicine.1

Some ophthalmologists and optometrists use a protocol wherein patients are offered non-mydriatic fundus photography or posterior-segment OCT to screen for posterior segment disease and to educate patients about the back of the eye. This is usually done prior to any eye exam, and there is no patient-specific order for the test.

Prophylactic testing is part of a wellness program to check for disease that may otherwise go undetected. It is not required by medical necessity for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.2

“Screening” occurs when the images are taken for one or more of the following reasons:

  • Part of a wellness program to check for disease that may otherwise go undetected
  • Not required by medical necessity; the reason for doing them is optional
  • Recommended prior to an eye examination
  • If the images are usually taken before the patient is examined by the eye-care provider
  • If done for all patients as a matter of course, unless they decline

Q. If the screening tests reveal pathology, and additional tests are ordered, would those tests be covered?

A. Generally, yes, but with caveats. Finding disease on a screening test does not confer eligibility for reimbursement. It frequently leads to additional evaluation and management services, albeit not necessarily on the same day. Re-taking an image later on the same day as the screening image (or another day close in time to the initial test) does not support coverage.

Q. What documentation is required in the medical record?

A. Expected documentation includes interpretation of the test results with a notation of the findings and assessment. Without pathology or abnormalities, it is sufficient to note a finding such as “normal fundus.” If the test does reveal disease or abnormalities, a more extensive note includes findings, impression and/or diagnosis and a plan. Remember to sign the note.

Q. Some devices have both a screening mode and a diagnostic mode. Is this required?

A. No. The intent of the physician and patient governs whether a test is screening or medically necessary. It may be handy to have a screening mode, but it is not required.

Q. What are the reimbursement issues?

A. The primary issue is who pays for the test — which depends on why the test is performed. In most cases, screening services are not covered by medical insurance, including Medicare. Patients are responsible for charges for preventative testing associated with a screening program.

It is necessary to advise the patient of financial responsibility in advance. Because screening tests are statutorily non-covered by Medicare, an Advance Beneficiary Notice of Noncoverage (ABN) form is not required. To avoid confusion, we recommend a Notice of Exclusion from Health Plan Benefits (NEHB) form instead. This also works for commercial insurance plans.

Unfortunately, for patients enrolled in Medicare Advantage (MA) plans (Medicare Part C), you may be required to get a prior determination of noncoverage from the MA plan. Check with the individual plans for their instructions.

Q. May screening tests be repeated?

A. Periodic wellness testing is reasonable at an appropriate interval, such as annually. However, once a patient has been diagnosed with a medical condition for which the testing is required, then the usual medical necessity guidelines apply to frequency of testing and the tests would no longer be considered screening.

Q. How should we track the screening test in our billing system?

A. Because this is a noncovered service paid by the patient, it is unlikely that a claim will be filed. For bookkeeping purposes and to avoid confusion for the patient, a distinct charge for the test should be entered into the patient account. HCPCS code S9986 “not medically necessary service” is useful for this purpose, or you can create an internal code.

If a patient insists that a claim be filed, report the usual test code with modifier GY. Modifier GY means an “Item or service statutorily excluded or does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.” This modifier ensures a denial. Couple this with a diagnosis code indicative of screening, such as Z00.-, “Unspecified general medical examination,” which includes a general vision examination, or Z01.0-, “Special investigations and examinations, eyes and vision”. OM

REFERENCES

  1. CFR 410.32 (a)
  2. The definition of covered services under the Medicare program, based on the Social Security Act §1862(a)(1)(A).