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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