The physician’s order helps establish the medical necessity for the service.
Recently, an ophthalmology practice purchased a scanning computerized ophthalmic diagnostic imager (SCODI). Because the physician has been ordering these tests on most glaucoma patients, the technician decides to perform the test in advance of the patient seeing the doctor for a glaucoma follow-up exam. She believes this is a more efficient use of time since the physician will almost certainly want the patient tested.
In this instance, the physician is unaware that the test was performed and does not see the test printout. No interpretation of the test exists in the patient record. Since the technician noted the test on the encounter form (also known as the superbill), the claim for today’s visit includes SCODI for both eyes (92135-50) and an office visit.
Is billing for the SCODI appropriate?
The definition in the CPT book for 92135 is “Scanning computerized ophthalmic diagnostic imaging (eg, scanning laser) with interpretation and report, unilateral.” The CPT book describes interpretation and report under the special ophthalmological services section as follows:
“Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Technical procedures (which may or may not be performed by the physician personally) are often part of the service, but should not be mistaken to constitute the service itself.”
The phrase “with interpretation and report” is found in the description of many ophthalmic diagnostic tests. This does not mean that a lengthy or dictated report is required. It does mean that the physician must look at the results of the test, make an interpretation and place a notation in the patient’s medical record within a short time of the test results being available. Best practices stipulate that interpretation of a diagnostic test includes the following:
An assessment of whether the test was reliable;
The results of the test, including noteworthy findings (if any);
Implications of the test, including diagnosis (if possible);
The impact of the test results on the patient’s treatment and/or prognosis; and
The physician’s signature.
An interpretation may be written on a separate page in the medical record, as a discrete entry together with other evaluation and management services, or in the blank space on the printout of the test results (eg, the SCODI).
In this case, the physician did not review the SCODI. No report exists. At a minimum, the professional component would be considered an overpayment. The technical component may also be denied, under the theory that without the interpretation the service was of no value to the patient.
Furthermore, no order exists in the patient’s chart for the SCODI. All diagnostic tests require a physician’s order. It is usually noted as part of the plan in the medical record. It may be a notation as simple as “SCODI today.” While a “standing order” may improve office efficiency, it usually creates problems with reimbursement.
Reimbursement for diagnostic tests depends on the appropriateness of and medical necessity for the service. Medicare’s policy, in CFR 42 §410.32, states, “All diagnostic x-ray tests, diagnostic laboratory tests and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.”
The physician’s order helps establish the medical necessity, providing the rationale or justification for the service. Tests performed from a standing order often result in a medically unnecessary service or routine service being performed.
Even though medical necessity may be supported due to the patient’s condition, failure to have a specific order or interpretation in the record leaves no documentation to support the claim.