coding strategies

Ophthalmic Testing: A Look at Specular Microscopy

BY CLARKE D. NEWMAN, OD, FAAO

In 2008 I laid out, bit by bit, a method for understanding the correct way to bill for your medically necessary contact lens services. This year, we'll drill a little deeper into some special topics.

We'll begin by looking at the general ophthalmologic codes, which are the 92xxx CPT codes. Specifically, I want to focus on specular microscopy.

Many optometrists are now performing specular microscopy. Specular microscopy is CPT code 92286. The plain language of this code is, "Special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count."

If you think back to early columns from last year, you have entered into contracts with each carrier to abide by the edicts of CPT unless modified by a directive from the carrier. For Medicare, that would be through National and Local Coverage Determinations (NCDs and LCDs).

For each carrier, you have a responsibility to know, each year, whether a carrier policy modifies the plain language of CPT for a particular code. In 2009 in Dallas, for all of the insurance companies with whom I am empanelled, there is only one policy regarding specular microscopy. So, unless you're on the same panels I am, I can't tell you whether the rules are the same for you.

I can tell you that one policy applies to all of us. It is a Medicare NCD 80.8 out of PUB 100-3. It states that medical necessity is established for specular microscopy when the patient:

• Has slit lamp evidence of endothelial dystrophy (corneal guttata).
• Has slit lamp evidence of corneal edema.
• Is about to undergo a secondary intraocular lens implantation.
• Has had a previous intraocular surgery and requires cataract surgery.
• Is about to undergo a surgical procedure associated with a higher risk to corneal endothelium; e.g., phacoemulsification or refractive surgery (excluding keratophakia and radial keratotomy under NCD 80.7).
• Has evidence of posterior polymorphous dystrophy of the cornea or irido-corneal-endothelial syndrome.
• Is about to be fitted with extended wear contact lenses after intraocular surgery.

Other conditions might support medical necessity, but might require a letter of medical necessity. It is perfectly rational to do specular microscopy on keratoconus patients, for example — just have your letters ready when you get rejected.

The Audit Proof Record

If you look at the plain language of the CPT code, you can see that you must photograph the eye with a specular microscope, which requires an image capture stored as a printed or digital photograph. You must also make a report of your interpretation.

The audit proof patient record would contain a chief complaint that is rational to one of the seven test indications just listed, a properly documented history of present illness that supports the chief complaint, the presence of one of those five conditions, the specular photograph, a written interpretation of test results and a note of how that interpretation affects treatment.

The one thing you do not have to have to bill for specular microscopy is a specular microscope. It helps, but you can bill the code with the –26 modifier and just get paid for the professional component while someone else does the image and bills the –TC modifier for the technical component. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery. He is also a consultant to Bausch & Lomb.