Coding and Billing

How to Document for Out-of-Pocket Screenings

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Nov. 7, 2018

Screenings that are not covered by patient insurance are becoming more common. Here’s the documentation your practice must do when these screenings take place.

Screening retinal photographs are a common procedure done in eyecare offices. Screening tests are not medically necessary tests, therefore, cannot be billed to a third party. You can bill the patient, but there are two rules to keep in mind.

1) Have the patient sign an Advance Written Notice of Non-coverage. In the Medicare world (but these also work for any commercial carrier), pick the form that is most appropriate for the patient you are seeing. These documents are:

a. Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131

b. Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Form CMS-10055

c. Home Health Change of Care Notice (HHCCN), Form CMS-10280

d. Hospital-Issued Notice of Noncoverage (HINN)

2) You must explain to the patient and document on the form why the service or procedure is not covered.

The three most common reasons for non-coverage include:
• When an item or service is considered not medically necessary
• When a service is not indicated for diagnosis and/or treatment
• When more than the number of services allowed in a specific period for the corresponding diagnosis or treatment occurs

If, during the screening retinal photo, a medical issue is discovered, the eyecare provider can order a medically necessary retinal photo as long as the new test provides additional information not present in the screening results.

Some consultants say that this second test can be done on the same day as the screening test. We suggest it is safer to do it on a different day when possible and when waiting does not negatively impact the patient. The concern third parties have is called “bait and switch.” Bait and switch is where you offer a patient a lower fee for a procedure, then you raise the fee on the same visit. For example, the patient is told the screening fee for the retinal photo is $29, but suddenly you’ve billed $79 because you found something and are now calling it a medically necessary retinal photo.

DOCUMENTATION
Even though it is a screening test, you should document the following in your patient’s primary medical record:
• A reference to where the image/test results are stored
• The patient’s name
• The date of the screening test
• A statement about the results of the screening test
• Your signature

Remember the documentation rule that if you discover a problem, you must further describe it in words or pictures, and you should include in your primary medical record your impressions, diagnosis and treatment plan for the problem you discovered.

CODING
What code should be used for a screening test? You could code S9986 – payable by the patient. You want to make a notation that the test is “not medically necessary.” Some carriers will not accept S9986. If the patient insists a claim be filed, then you could report 92250 with a modifier. The modifiers to consider are: GA is expected not to be covered and GZ is unnecessary procedure. (For Medicare, modifier GY is used with 92015 because it is statutorily excluded.)

You should be aware that some carriers now cover retinal screening photos. When this happens, follow the carrier’s policies exactly.

Screening tests give the eyecare provider powerful tools to catch problems earlier and, therefore, begin treatment earlier, leading to better outcomes. Follow the rules for screening tests as you utilize these powerful and helpful tools.

References
i. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

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