asoa course id: 3808 title: supplemental diagnostic testing...

I N S T R U C T O R : D I A N E C . F U L T O N , C P P M

( A A P C C E R T I F I E D P H Y S I C I A N P R A C T I C E

M A N A G E R )

ASOA COURSE ID: 3808

TITLE: SUPPLEMENTAL DIAGNOSTIC TESTING WITH VISUAL

ELECTROPHYSIOLOGY (1 HOUR)

DISCLOSURE

• AVP Insurance and Practice Development, Diopsys,

Inc.

• Adjunct Physician Practice Management and

Billing, County College of Morris

• Provider and Patient Advocate, Multiple providers

COURSE DESCRIPTION

Course will provide resources for use and

integration of medically necessary, ancillary visual

electrophysiological diagnostic testing for office

based use.

Visual evoked potential (VEP) testing

Electroretinography (ERG)

LEARNING OBJECTIVES

Attendees will understand how VEP and ERG expand

practice diagnostics.

Meet clinical objectives for patient care, and

Leverage the practice for growth in the community

through co-management with other specialties.

WHAT IS VISUAL ELECTROPHYSIOLOGY?

ERG

VEP

www.intechopen.com Figure 13. Human Visual Pathway http://www.austincc.edu/apreview/PhysText/PNSafferentpt2.html

COMPONENTS OF THE DEVICE

Computer with specialized software and hardware

2 screens, on for operator

and one for patient stimulus

Sensors for the head to

lead wires

Lead wires to Signal amplifier

Signal amplifier to computer

Computer for analysis and

report

http://www.sgrh.com/departments/neurophysiology

CONSIDERATIONS FOR ADDING DIAGNOSTICS TO THE PRACTICE

Professionally Accepted

• Clinically Useful

• Medically Necessary

• Financially Feasible

PROFESSIONALLY ACCEPTED IN OPHTHALMOLOGY


“The examination includes a careful and thorough detection and diagnosis of

ophthalmic disorders, implementation of appropriate therapy for refractive error

and both ocular and systemic disease.”

http://www.aaojournal.org/article/S0161-6420(15)01269-5/pdf

“Based on the patient's history and findings, additional tests or

evaluations might be indicated to evaluate further a particular structure

or function. These are not routinely part of the comprehensive medical

eye clinical evaluation.”

Additional diagnostic testing may include the following: ‹

Keratometry (e.g., to assess surface quality and power) ‹

Corneal topography/tomography, including analysis ‹

Measurement of corneal thickness (pachymetry, corneal tomography) ‹

Corneal endothelial cell analysis ‹

External, slit-lamp, or fundus photography ‹

Anterior and posterior segment imaging (e.g., optical coherence tomography [OCT], anterior

segment OCT, ocular photography, high-frequency ultrasonography, or confocal microscopy) ‹

Visual fields by automated and/or manual perimetry ‹

Biometry ‹

Stereophotography or computer-based image analysis of the optic disc and retinal nerve fiber layer o macula ‹

Ophthalmic ultrasonography ‹ Fluorescein or indocyanine green angiography ‹

Electrophysiological testing ‹

Microbiology and cytology of ocular or periocular specimens ‹

In-office point-of-care testing (e.g., immunochromatography) ‹

Radiologic imaging ‹

Laboratory tests for systemic disease



(ALTERNATIVE OR ADDITIONAL) AAO Education and Acceptance:

• Core Ophthalmic Knowledge – alternative for visual acuity

• AAO Program Director’s Handbook – diagnostic and therapeutic role of

electrophysiology

• Basic Clinical Science Courses • Visual Field - alternative methods to measure visual function.

• Pediatric Ophthalmology and Strabismus – alternative method of visual acuity,

asymmetries and quantitative information

• Glaucoma – pattern ERG for early glaucomatous visual function loss

• Retina and Vitreous - ancillary studies for diagnosis of vitreoretinal disorders and

optic nerve conduction, ischemic or nonischemic vein occlusions, monitor disease

activity and progression, distinction from congenital motor nystagmus or ocular

albinism, congenital stationary night blindness (CSNB), hereditary retinal and

choroidal dystrophies, systemic congenital and metabolic disorders, albinism,

systemic retinal drug induced toxicities (e.g. sildenafil/Viagra, tadalafil/Cialis,

plaquenil/RA/Lupus, cardiac glycoside digitalis/Cardiac, isotretinoin/Acne,

vigabatrin/Antiepileptic, Tamoxifen/Chemo, hereditary hyaloideoretinopathies,

retinal toxicities from retained intraocular foreign bodies (e.g. zinc, aluminum,

copper, iron/siderosis),

http://one.aao.org/CE/EducationalProducts/snippet.aspx?F=bcsccontent\bcscsection10\bcsc2007section10

_2007-07-12_010741\clinicalevaluation\bcsc10030033.xml&popup

PROFESSIONALLY ACCEPTED IN OPTOMETRY


• American Optometric Association OPTOMETRIC CLINICAL PRACTICE

GUIDELINES: • COMPREHENSIVE ADULT EYE AND VISION EXAMINATION

Supplemental Testing: Confirm or rule out differential diagnoses, Enable more in-depth assessment, Provide alternative means of evaluating patients who may not be fully cooperative or who may not comprehend testing procedures

• Care of the Patient with Visual Impairment “The electrodiagnostic tests (VEP, ERG, and EOG) are important in

clarification of diagnoses, particularly when clinical information is inconsistent, or when the patient is very young or multiply handicapped.”

http://www.optometry.org/pdf/matrix/pdf/part_abs_matrix.pdf

http://www.aoa.org/documents/CPG-14.pdf

http://www.aoa.org/documents/optometrists/CPG-1.pdf


• American Optometric Association OPTOMETRIC CLINICAL PRACTICE

GUIDELINES:

• Optometric Care of the Patient with Acquired Brain Injury

OPTOMETRIC EVALUATION AND MANAGEMENT

• Care of the Patient with Learning Related Vision Problems

• Pediatric Eye And Vision Examination

• Care of the Patient with Amblyopia

http://c.ymcdn.com/sites/www.covd.org/resource/resmgr/position_papers/acquired-brain-injury_-_aoa.pdf






Clinically Useful

• Medically Necessary


OCULAR DISORDERS THAT AFFECT NEUROLOGICAL FUNCTION OF VISION


http://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp--october-2011

• Amblyopia

• Open-angle glaucoma

• Primary angle-closure glaucoma

• Diabetic retinopathy

• Diabetic Macular Edema

• AMD

• Epiretinal membrane

• CRAO or CRVO

• Disorders behind Cataract

• Questionable vision

SYSTEMIC DISEASES AND CONDITIONS THAT AFFECT VISUAL FUNCTION

“Important ophthalmic manifestations associated with systemic

• infectious,

• neoplastic,

• autoimmune,

• vascular, and

• nutrition-related diseases

may be discovered during the ocular examination. Therefore, findings that lead to the diagnosis of a number of systemic diseases may be revealed during a comprehensive ophthalmic evaluation.”


SUBCLINICAL VISUAL DYSFUNCTION IS NOT ALWAYS OBVIOUS

CLINICALLY USEFUL

• Subclinical – below the level of detection

• Equivocal – questionable, atypical

• Location – isolate the dysfunction

• Progression – monitor for severity, treatment efficacy

The clinical role of evoked potentials

http://jnnp.bmj.com/content/76/suppl_2/ii16.full

SUBCLINICAL OCULAR DISORDERS OF THE VISUAL PATHWAY

https://commons.wikimedia.org/wiki/File:Human_visual_pathway.svg

Retinal dysfunction:

• Glaucoma

• AMD

• DR

• DME

• Toxicities of Retina

Visual Pathway dysfunction:

• Amblyopia

• Optic Neuritis

• Trauma

• Toxicities of Pathway

Electroretinogram (ERG)

CPT 92275 C

P

T

9

5

9

3

0

Visual Evoked Potential (VEP)

SUBCLINICAL SYSTEMIC/CAUSES THAT AFFECT THE VISUAL PATHWAY

https://commons.wikimedia.org/wiki/File:Human_visual_pathway.svg

CPT ERG 92275

V

E

P

9

5

9

3

0

International Society for Clinical Electrophysiology of

Vision: VISUAL ELECTRODIAGNOSTICS

A Guide To Procedures http://www.iscev.org/standards/proceduresguide.html

PROFESSIONAL ACCEPTANCE MEETS CLINICAL USE WITH “DOCUMENTATION”

“Doc, you meant to…….”

CIRCUMSTANCES CLINICAL USE

Is it ophthalmic or from another cause?

Where’s the dysfunction?

ADJUNCTIVE TESTING FOR EQUIVOCAL CIRCUMSTANCES (NOT SURE)

Complaints or standard tests results are

questionable, need comparative data

ADJUNCTIVE TESTING FOR EQUIVOCAL CIRCUMSTANCES (NOT SURE)

Locate Dysfunction

Monitor Disease Activity and Progression for Severity,

Treatment Efficacy and Comparative Data

COMMON CIRCUMSTANCES FOR ALTERNATIVE TESTING

When standard tests are inconclusive

COGNITIVE, LANGUAGE AND SPECIAL NEEDS

https://www.google.com/search?q=images+difficult+eye+exam&espv=2&biw=1280&bih=919&tbm=isch&tbo=u&source=univ&s

a=X&ved=0ahUKEwikzom7u6_LAhUmtYMKHZH_A2sQsAQITQ#imgrc=DoUo6BLPtRmAuM%3A

COMMON CIRCUMSTANCES FOR ALTERNATIVE TESTING

Patient testing difficulties

SUMMARY FOR CLINICAL USE

Think

Circumstances

for testing

Then select

the test base

on the area of

concern



Clinically Useful

Medically Necessary


“DOC, YOU MEANT TO…”

Medical Necessity

Objectives

Documentation

WHAT IS MEDICAL NECESSITY?

• “reasonable and necessary for the diagnosis or

treatment of illness or injury or to improve the

functioning of a malformed body member.”

https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

KNOW OPHTHALMOLOGIST CLINICAL OBJECTIVES

“CLINICAL OBJECTIVES :‹

• Detect and diagnose ocular abnormalities and diseases ‹

• Identify risk factors for ocular disease ‹

• Identify risk factors for systemic disease based on ocular findings ‹

• Establish the presence or absence of ocular signs or symptoms of systemic disease ‹

• Determine the refractive state and health status of the eye, visual system, and related structures ‹

• Discuss the results and implications of the examination with the patient ‹

• Initiate an appropriate management plan, including determination of the frequency of future visits, further diagnostic tests, referral, or treatment”


DOCUMENT NEED AND CLINICAL OBJECTIVES ON INTERPRETATION AND

REPORT

• Interpretation and Report

• Patient Name

• Reason for Service

• Test Result

• Impression and diagnosis

• Better, worse, stable

• Impact on Care

• Signature and Date

EXAMPLE OF HOW ERG AND/OR VEP IMPACT CARE

Results provide more specific, objective

and in-depth comparative data

More objective Impression

Consistent with Clinical Objectives

KNOW ICD CODING GUIDELINES

• Get coding order right - code the chief reason for

the test, list first the sign or symptom in absence of a

diagnosis.

“G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by

the physician.”

• “Suspected” diagnoses - coding signs, symptoms

and abnormal test results if diagnosis is uncertain.

“Uncertain diagnosis Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest

degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf

LOCATE, DIAGNOSE, PATHWAY CONCERN/NORMAL VEP

• Physician Order : • VEP – CPT 95930

V

E

P

Code Confirmed Diagnosis

• VEP Test result:

• Normal

• Chief Reason for Service: • Patient “can’t see,” recent emotional trauma • Questionable Vision in Pathway • ICD H53.16 - Unreliable Visual Field (psychophysical visual disturbance)

• Need ERG? – CPT 92275 • Only if specific retinal function concern, otherwise, is

ERG medically necessary?

• Diagnosis: • F44.6 -Conversion disorder with sensory

symptom or deficit

V

E

P

LOCATE, DIAGNOSE, NEURO CONCERN/ABNORMAL VEP

• Physician Order : • VEP – CPT 95930 • ERG – CPT 92275

V

E

P

• Test result:

• VEP abnormal OU • ERG Normal OU

• Chief Reason for Service: • Questionable Vision in Pathway • ICD H53.16 - Unreliable Visual Field (psychophysical visual disturbance)

V

E

P

NL ERG OS NL ERG OD

• Diagnosis: • VEP -

• H53.16 – Unreliable Visual Field • R94.112 – Abnormal VEP

• ERG - R94.112 - Abnormal VEP

Code abnormal test if

no confirmed diagnosis

LOCATE, DIAGNOSE, PATHWAY AND RETINA DYSFUNCTION

• Physician Order : • VEP – CPT 95930 • ERG – CPT 92275

V

E

P

Code disorder, not

abnormal VEP

• Test result: • VEP Abnormal OU • ERG Abnormal OU

• Chief Reason for Service: • Questionable Vision in Pathway

• ICD H53.16 - Unreliable Visual Field (psychophysical visual disturbance)

• Diagnosis: • VEP –

• H53.16 - Unreliable Visual Field • R94.112 - Abnormal VEP

• ERG – • H35. 9 - Unspecified retinal disorder

V

E

P

ABN ERG ABN ERG

LOCATE, MEASURE, DIAGNOSE RETINAL DYSFUNCTION

• Physician Order : • Return for ERG – CPT 92275

• Test results: • ERG Abnormal retinal function OD, OS changing

• Chief Reason for Service: • 65 y/o Caucasian, smoker, family hx of AMD • Chief Complaint – Changes to vision, unreliable visual field test H53.16

• Cups borderline, IOP normal, OCT normal • Drusen detected during exam OS

• H35.362 …… left eye

• Diagnosis: ERG – H40.021 Open angle with borderline findings, high right eye H35.362 …… left eye

ABN ERG ABN ERG

ERG clarified new dx H35.362

B

H53.16

05 06 16

05 09 16

92014

H40.021



Clinically Useful

Medically Necessary

Financially Feasible

FINANCIALLY FEASIBLE

• Cost of Visual Electrophysiology Equipment:

• Varies by Manufacturer (e.g. $40-$60K)

• Meet your needs

• Less than OCT (e.g. $50-$80k)

• Supplies/Electrodes vary

• Administration – staff time

• Service and Support (training and maintenance)

• think about EMR model

NATIONALLY COVERED

Manual Section Title : Evoked Response Tests

Benefit Category: Diagnostic Tests (other)

Item/Service Description: These tests measure brain responses to repetitive visual, click or other stimuli.

Indications and Limitations

of Coverage: Evoked response tests, including brain stem evoked response and visual evoked response tests, are

generally accepted as safe and effective diagnostic

tools. Program payment may be made for these

procedures.

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=200&ncdver=1&bc=AAAAQAAAAAAA&

CMS 2016 NATIONAL PHYSICIAN FEE SCHEDULE

CPT/Modifier

NON-FACILITY

PRICE

NON-FACILITY LIMITING CHARGE

WORK RVU

TRANSITIONED NON-

FAC PE RVU

MP RVU

TRANSITIONED

NON-FAC TOTAL

MULT SURG

BILT SURG

PHYS SUPV

92275 ERG $149.66 $163.51 1.01 3.14 0.03 4.18 7 2 9 26 $54.78 $59.85 1.01 0.51 0.01 1.53 7 2 9 TC $94.88 $103.66 0 2.63 0.02 2.65 7 2 1

95930 VEP $131.04 $143.17 0.35 3.28 0.03 3.66 0 2 9 TC $112.07 $122.43 0 3.11 0.02 3.13 0 2 9 26 $18.98 $20.73 0.35 0.17 0.01 0.53 0 2 9

Based on: • GPCIs = 1

• Conversion Factor = 35.8043 • Multiple Procedure Payment Reduction = 7 • Bilaterally Billed = 2 • Physician Supervision:

• 0= does not apply • 1 = general supervision

https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=4&HT=1&CT=0&H1=95930&H2=92275&M=5 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/How_to_MPFS_Booklet_ICN901344.pdf

COMMON ICDS COMMON QUESTIONS

• Frequency?

• When medically necessary

• Both tests on same day?

• No NCCIs (National Correct Coding Initiatives)

• MPPR (Multiple Procedure Payment Reduction) only applies to ERG 92275

• Billed with office visit?

• If office visit was performed/documented

• No 99211 on ERG due to NCCI

COMMON QUESTIONS

• Documentation?

• Like any other dx test that requires and Interpretation and Report

• Special Billing Instruction?

• HCFA 1500 box 17 requires name and NPI of referring/ordering doctor

• ICD coding?

• List first the chief reason the service was provided or the final diagnosis

PRACTICE VALUE

To and From Specialists : For (e.g.):

Endocrinology and Internal Medicine Vascular diseases like diabetes

Neurology, Rehabilitation Medicine Neurology for MS, trauma

Infectious Disease Infectious Disease for viral and bacterial

Rheumatology Autoimmune disorders

Hematology/Oncology Neoplastic, infiltrations in the brain and eye

Gastroenterology/Endocrinology Nutrition-related disease

Pediatrics Children with special testing needs

• More sensitive, specific testing to differentiate ocular from systemic

or other causes (trauma)

• Positive practice image offering more advanced diagnostics

• Build referral relationships to and from other specialists' for co-

management

Market practice for disorders that affect vision

SUMMARY

• Professionally and clinically accepted in vision care

• Specific for circumstances and conditions for which

there is not substitute

• Medically necessary for coverage

• Valuable addition for patient care and the practice

QUESTIONS?

• Contact

• [email protected]

• 973 244-0622 x 322

asoa course id: 3808 title: supplemental diagnostic testing...

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