Ophthalmology and Optometry Coding Alert

Billing for Schirmer's test and getting denied can be aggravating. Understanding how Medicare and private payers consider this procedure, however, should save you time and discontent.

A Schirmer's test, or tear test, determines the amount of tears the eye produces. For patients with dry-eye syndrome, the test indicates whether the eye produces enough tears to keep it moist: ICD-9 375.15 (Tear film insufficiency, unspecified). It can also be used in cases where excessive watering of the eyes occurs: 375.11 (Dacryops) or 375.20-375.22 (Epiphora).

For the test, small filter paper strips are inserted into the conjunctival sacs of both eyes simultaneously for five minutes to measure tear production. Sometimes a topical anesthetic is administered prior to the paper insertion to prevent tearing from irritation caused by the paper. The eyes are closed during the test duration. At the test conclusion, the amount of moisture is measured.

If you performed the procedure solely to test for dry eyes or a tearing problem, you can avoid billing and audit  hassles by understanding that this test is not billable as a separate procedure for most insurers and Medicare.

In an optometry billing guide, one Medicare carrier considers Schirmer's test to be an integral part of the evaluation and management service and, therefore, it is not reimbursed separately. Other services listed as "included" in E/Ms are glare test, keratometry, and brightness acuity or glare testing. Medicare and most other payers consider the test to be part of a routine eye exam.

Whereas you can use the unlisted-procedure code 92499 (Unlisted ophthalmological service or procedure) or code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) to bill services like this that do not have their own CPT code to insurance companies other then Medicare, the problem lies in providing the documentation of the service and cost information, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

To bill services with 92499, you need to list the name of the service in either the comments area or box 19 of your claim form, and provide a copy of the report. If this were corneal topography, for example, you could submit a copy of the printout from the machine. With Schirmer's, however, your only test results are two used strips of paper. If you're determined, you can copy the progress note with the strips taped and submit them as documentation with 92499, she says.

To use 99070, you need to establish the cost of the supply used; this is typically done by providing a copy of the invoice that lists the supply item purchased. In this instance, because the strips are relatively inexpensive (after dividing the quantity of the box by the total price,  then multiplying that by two), your claim form and envelope, not to mention your time, will end up being more expensive than the reimbursement you will receive, Duran says.