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Answer: Catherine A. Brink, CMM, CPC, president of Healthcare Resources Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurology practices, states that most payers, including Medicare, reimburse for services based on medical necessity. The ICD-9 diagnosis code that is submitted with the service is often the key to proving the medical necessity for a provided service. Complete medical record documentation further substantiates medical necessity of the service rendered.
Payment of 92283 (color vision examination, extended, e.g., anomaloscope or equivalent) and 76857 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up) will depend on medical necessity for performing these services, namely the ICD-9 code submitted with the claim form. The neurologist should contact his or her major payers, such as Medicare, and provide them with the ICD-9 code(s) that will be submitted for these procedures to determine reimbursement. According to CPT 2000 in the parenthetical statement under code 92283, color vision testing with pseudoisochromatic plates (such as HRR or Ishihara) is not reported separately but included in the appropriate general or ophthalmological service.
The -59 modifier (distinct procedural service) would be appropriate because these two services are not reported together normally and are distinct and independent services. CPT 2000 cautions against the overuse of this modifier: When another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used.
Neurologists should note, however, that the correct use of modifiers doesnt guarantee payment. In some cases, insurers may have established policies that disallow or reduce payment on certain modifiers, or perhaps their computer software is an older version and simply doesnt recognize current modifier usage. In any event, coders should contact major payers to determine which modifiers they accept, which they deny, and which alternative coding techniques they require.
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