Ophthalmology and Optometry Coding Alert

Question: Does an ophthalmic technician fall under Medicares incident to rules? In other words, must the billing provider be on the premises at the time of the
A-scan or visual field test?

Anonymous Massachusetts Subscriber

Answer: Yes, an ophthalmic technician does fall under the incident to Medicare rules, but these rules do not require that the billing doctor be on the premises if it is a group practice setting. A doctor of the group must be on the premises to bill for the diagnostic test because a certified ophthalmic technician (COT) or certified ophthalmic assistant (COA) are just thatcertified. To be exempted from the incident to rules, the health care provider must be licensed by the state and listed in the Medicare Carriers Manual (MCM) as one of the recognized limited license providers.

For example, optometrists, nurse practitioners and physician assistants are listed in the MCM, but registered nurses are not. Limited license providers are considered physicians for purposes of billing Medicare, but only for those services the state has licensed them to perform (hence the limited license). This goes far beyond certification. For one thing, its the doctor who has the malpractice insurance, not the COTs and COAs. Even if the technician sees a patient and does a complete workup, the technician cant bill it. The physician is ultimately responsible for the exam and any diagnostic tests which are done.

The incident to guidelines in the MCM stipulate direct supervision, which means that the physician (or a physician of the group) does have to be present in the office and immediately available if needed, but does not have to be in the actual room where the service is being provided.

Federal Register final rule for Physician Supervision of Diagnostic Testing was published in the Oct. 31, 1997, Federal Register and was supposed to take effect Jan. 1, 1998. In the Federal Register final rule, all the testing codes were assigned one of three supervision levels: 1 meant general supervision (the physician would not have to be on premises), 2 meant direct supervision, and 3 meant personal supervision (the physician must be personally present in the room where the service is provided).

Normally, HCFA would revise the MCM guidelines to correspond to a new rule so that carriers would have the proper instructions for implementation. After these rules were published, however, HCFA put a hold on full implementation of the rule in order to study further the appropriate level of supervision for the various testing services affected. A HCFA letter was sent out directing local carriers to implement whatever levels of physician supervision local medical review policies (LMRP) they chose in the interim, until HCFA publishes the final implementation guidelines for carriers in the MCM.

Different carriers did indeed implement different LMRPs which were specific to certain testing services and continued to follow the direct supervision requirements spelled out in the MCM for all others. That is why there is some confusion about this question. In the Oct. 31, 1997, Federal Register for example, visual field codes (92081, 92082, 92083) were assigned a physician supervision value of 1, meaning general supervision. So according to HCFAs final rule, a doctor providing general supervision of a technician could bill for visual field exams. But HCFA never implemented that rule, and its now on hold for future revision of the list of testing services. Many carriers have decided to require that all such procedures be done under at least direct supervision (with a physician in the office) because that is what the MCM still states. So ultimately, you should check with your carrier to find any LMRPs on physician supervision and diagnostic testing.