Download ASOA Course ID: 3808 Title

ASOA COURSE ID: 3808
TITLE: SUPPLEMENTAL DIAGNOSTIC
TESTING WITH VISUAL
ELECTROPHYSIOLOGY (1 HOUR)
INSTRUCTOR: DIANE C. FULTON, CPPM
(AAPC CERTIFIED PHYSICIAN PRACTICE
MANAGER)
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?
VEP
ERG
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
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
PROFESSIONALLY ACCEPTED IN
OPHTHALMOLOGY
“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
PROFESSIONALLY ACCEPTED IN
OPHTHALMOLOGY
(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
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
PROFESSIONALLY ACCEPTED IN
OPTOMETRY
• 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
http://www.aoa.org/documents/CPG-20.pdf
http://www.aoa.org/documents/CPG-2.pdf
http://www.aoa.org/documents/CPG-4.pdf
CONSIDERATIONS FOR ADDING
DIAGNOSTICS TO THE PRACTICE
 Professionally Accepted
 Clinically Useful
•
Medically Necessary
•
Financially Feasible
OCULAR DISORDERS THAT AFFECT
NEUROLOGICAL FUNCTION OF VISION
•
•
•
•
•
•
•
•
•
•
Amblyopia
Open-angle glaucoma
Primary angle-closure glaucoma
Diabetic retinopathy
Diabetic Macular Edema
AMD
Epiretinal membrane
CRAO or CRVO
Disorders behind Cataract
Questionable vision
http://www.aaojournal.org/article/S0161-6420(15)01269-5/pdf
http://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp--october-2011
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.”
http://www.aaojournal.org/article/S0161-6420(15)01269-5/pdf
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
Electroretinogram (ERG)
Retinal dysfunction:
• Glaucoma
• AMD
• DR
• DME
• Toxicities of Retina
CPT 92275
Visual Evoked Potential (VEP)
Visual Pathway dysfunction:
• Amblyopia
• Optic Neuritis
• Trauma
• Toxicities of Pathway
https://commons.wikimedia.org/wiki/File:Human_visual_pathway.svg
C
P
T
9
5
9
3
0
SUBCLINICAL SYSTEMIC/CAUSES THAT
AFFECT THE VISUAL PATHWAY
International Society for Clinical Electrophysiology of
Vision: VISUAL ELECTRODIAGNOSTICS
A Guide To Procedures
http://www.iscev.org/standards/proceduresguide.html
CPT ERG 92275
V
E
P
9
5
9
3
0
https://commons.wikimedia.org/wiki/File:Human_visual_pathway.svg
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
CONSIDERATIONS FOR ADDING
DIAGNOSTICS TO THE PRACTICE
 Professionally Accepted
 Clinically Useful
 Medically Necessary
•
Financially Feasible
“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”
http://www.aaojournal.org/article/S0161-6420(15)01269-5/pdf
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-10CM 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
•
Chief Reason for Service:
• Patient “can’t see,” recent emotional trauma
• Questionable Vision in Pathway
• ICD H53.16 - Unreliable Visual Field
(psychophysical visual disturbance)
•
Physician Order :
• VEP – CPT 95930
•
VEP Test result:
• Normal
•
Diagnosis:
• F44.6 -Conversion disorder with sensory
symptom or deficit
•
Need ERG? – CPT 92275
• Only if specific retinal function concern, otherwise, is
ERG medically necessary?
V
E
P
V
E
P
Code Confirmed Diagnosis
LOCATE, DIAGNOSE, NEURO
CONCERN/ABNORMAL VEP
•
Chief Reason for Service:
• Questionable Vision in Pathway
• ICD H53.16 - Unreliable Visual Field
(psychophysical visual disturbance)
•
Physician Order :
• VEP – CPT 95930
• ERG – CPT 92275
Test result:
• VEP abnormal OU
• ERG Normal OU
•
•
Diagnosis:
• VEP • H53.16 – Unreliable Visual Field
• R94.112 – Abnormal VEP
• ERG - R94.112 - Abnormal VEP
NL ERG OD
NL ERG OS
V
E
P
V
E
P
Code abnormal test if
no confirmed diagnosis
LOCATE, DIAGNOSE, PATHWAY AND
RETINA DYSFUNCTION
•
Chief Reason for Service:
• Questionable Vision in Pathway
• ICD H53.16 - Unreliable Visual Field
(psychophysical visual disturbance)
•
Physician Order :
• VEP – CPT 95930
• ERG – CPT 92275
•
Test result:
• VEP Abnormal OU
• ERG Abnormal OU
•
Diagnosis:
• VEP –
• H53.16 - Unreliable Visual Field
• R94.112 - Abnormal VEP
• ERG –
• H35. 9 - Unspecified retinal disorder
ABN ERG
ABN ERG
V
E
P
V
E
P
Code disorder, not
abnormal VEP
LOCATE, MEASURE, DIAGNOSE RETINAL
DYSFUNCTION
•
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
•
Physician Order :
• Return for ERG – CPT 92275
•
Test results:
• ERG Abnormal retinal function OD, OS changing
•
Diagnosis:
ERG – H40.021 Open angle with borderline findings, high
right eye
H35.362 …… left eye
H53.16
05 06 16
05 09 16
ABN ERG
ERG clarified new dx
H40.021
H35.362
92014
ABN ERG
B
CONSIDERATIONS FOR ADDING
DIAGNOSTICS TO THE PRACTICE
 Professionally Accepted
 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
92275 ERG
26
TC
95930 VEP
TC
26
NONFACILITY
PRICE
$149.66
$54.78
$94.88
$131.04
$112.07
$18.98
TRANSITIO
NON-FACILITY
NED NONLIMITING
WORK FAC PE
CHARGE
RVU
RVU
$163.51
1.01
3.14
$59.85
1.01
0.51
$103.66
0
2.63
$143.17
0.35
3.28
$122.43
0
3.11
$20.73
0.35
0.17
MP
RVU
0.03
0.01
0.02
0.03
0.02
0.01
TRANSITI
ONED
NON-FAC MULT BILT PHYS
TOTAL SURG SURG SUPV
4.18
7
2
9
1.53
7
2
9
2.65
7
2
1
3.66
0
2
9
3.13
0
2
9
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-NetworkMLN/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
• 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 comanagement
Market practice for disorders that affect vision
To and From Specialists :
For (e.g.):
Endocrinology and Internal Medicine
Neurology, Rehabilitation Medicine
Vascular diseases like diabetes
Neurology for MS, trauma
Infectious Disease
Rheumatology
Hematology/Oncology
Gastroenterology/Endocrinology
Pediatrics
Infectious Disease for viral and bacterial
Autoimmune disorders
Neoplastic, infiltrations in the brain and eye
Nutrition-related disease
Children with special testing needs
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