Ophthalmology and Optometry Coding Alert

The Tensilon test (95857) is for myasthenia gravis, an abnormality of the nerve-muscle junction; eye signs of the disease include ptosis and double vision. The exact definition, in CPT, is simply Tensilon test for myasthenia gravis. This brief definition gives absolutely no idea of the time that can be involved for the procedure.

The Tensilon (edrophonium chloride) is given intravenously, in divided doses. If the first dose produces an improvement in the ptosis and double vision, the test is considered positive. If there is no response, then another dose is given. If there is no response to the second dose, then a third dose is given.

There is about a 15-minute wait in between doses, during which the patient must be monitored for side effects of the Tensilon. These side effects, which include lacrimation, nausea, and vomiting, must be counteracted by immediate atropine sulfate injection. So the atropine must be on hand every time a Tensilon test is done.

As Sheila Black from EyeCare Cullman asks, How do we code the length of time the ophthalmologist takes with a patient doing the Tensilon test? Black also wonders how to charge for the atropine which must be on hand.

The RVU for 95857 is 1.10; it doesnt pay very well, notes Raequell Duran, COA, president of Practice Solutions of Bakersfield, CA, and an ophthalmology coding and reimbursement consultant. Obviously, you would be charging an E/M services code for the visit as well, but its easy to understand why ophthalmologists want to know how to get reimbursed for their time. There are prolonged services codes (99354-99357), which are to be used for prolonged service beyond the usual service, according to CPT. However, the serial doses given in the Tensilon test are not beyond the usual service: That is the service, Duran says.

Perhaps a patient will react to the first dose as positive, but it may take three doses; three doses are not beyond the usual service. Therefore, caution would say that you should not use prolonged services codes (99354-99357) for this test, unless there were services performed beyond the clinical protocol for the Tensilon test, says Duran. The procedure is already priced out in the code. It is possible that you could use prolonged services codes (99354-99357) or the modifier -22 (unusual procedural services) if the procedure involved complications, but a report would probably have to be filed as well, she adds.

Medicare does pay for injectable drugs (although it doesnt pay for topical drugs such as eye drops or ointments). The J-code for atropine sulfate (up to 0.3 milligrams) is J0460. Check with your carrier for special coverage instructions for the atropine.