Pediatric Coding Alert

If you want to test nonverbal patients for visual impairments, you may want to consider a visual evoked potentials machine that insurers often cover per test from a low of $30 to a high of $160.

Although payment for vision screening (99173, Screening test of visual acuity, quantitative, bilateral) can prove hard to come by, reimbursement is much more straightforward for VEP test code 95930 (Visual evoked potential [VEP] testing central nervous system, checkerboard or flash). Instead of the SureSight Vision Screener (99173), "I use the VEP machine (95930)," says Richard Lander, MD, FAAP, a pediatrician at Essex-Morris Pediatric Group in Livingston, N.J. "It is a good screening test for amblyopia that is able to test kids as young as 6 months old."

The American Academy of Pediatrics Bright Futures evidence-based age-specific guidelines recommend that children have an early childhood vision screen at age 3 or 4 years. And the U.S. Preventive Task Force, an independent panel of experts in primary care and prevention that reviews the evidence of effectiveness and develops recommendations for clinical preventive services, recommends screening to detect amblyopia, strabismus and visual acuity defects in children younger than 5 years of age.

Benefit: A VEP machine, such as the Enfant Pediatric Vision Testing System manufactured by Diopsys, lets you detect visual deficits, such as optic nerve disorders, asymmetric refractive errors, and other problems that could lead to amblyopia in children who can't tell they have visual problems.

The child may be preverbal or unreliably tested with subjective vision tests, says Diane C. Fulton, director of insurance/medical coding and billing for Diopsys Inc. in Pine Brook, N.J. Or with older children, the patient may not recognize that he has a problem because his sight seems "normal" to him.

VEP testing provides the doctor with an objective assessment of a child's vision for appropriate referral, diagnosis and treatment. "It's just not practical to send every child to a specialist for a test that the patient's pediatrician can do," Fulton says. "This test makes a difference in children's lives by catching vision problems that could affect their development at a time when they are most receptive to treatment."

Easy: A physician extender can run the test, which has Federal Drug Administration approval for children ages 6 months to 8 years. The machine requires no technical certification. Diopsys provides complete training on the test's use.

CPT contains 95930 for VEP. Insurers reimburse the test 80 percent of the time, depending on your payer mix and geographic area, Fulton says.

The estimated 20 percent of payers that reject 95930 coverage usually do so due to contractual issues. "The insurer doesn't want to add the code to its capitation exceptions," Fulton says. "Or, the payer requires a specialist perform the test based on antiquated intra-operative VEP guidelines."

Medicare allows $108 (2.83 relative value units) for 95930 nationally. Therefore, for example from payers that pay 120 percent of the 2008 fee schedule, you can expect about $129. Insurers and Medicaid programs offer a wide range of 95930 payments.

Commercial plan payments range from $60 to $160. "Aetna sets the 'gold standard' of medical policies when it comes to VEP," Fulton says. The insurer recognizes the importance of early vision testing during a well check.

Most state Medicaid plans cover VEP. Ohio Medicaid pays the code at a low of $30, with many other state Medicaid plans paying about $90.

Some plans may have outdated VEP policies. For instance, Oxford's guidelines limit VEP coverage to the operating room or certain specialists. Surgeons often use VEP to monitor brain function when performing delicate operations close to the optic nerve. Some insurers need to update their policies to reflect the new use of VEP machines in primary care, Fulton says.

Action: Make a chart of your major payers' VEP policies focusing on noncovered versus covered. Fulton follows VEP reimbursement trends across the country and can help facilitate this process (dfulton@diopsys.com or 973-244-0622 ext 322). "If an insurer states it is not a covered service, the patient has the option to pay at the time of service," Lander says.

Although 95930's practice expense does not include the eye patch (A6411), payers generally don't cover the item.

Code 95930's Medicare fee schedule practice expense relative value units include the electrodes (A4556) and the conductive gel (A4558) associated with the test, says Richard Tuck, MD, FAAP, a prior member of the AMA's Specialty Society Relative Value Scale Update Committee.

Payers that follow the fee schedule may justifiably deny this additional charge as included in the payment for 95930.