{"id":23069,"date":"2018-11-06T10:11:09","date_gmt":"2018-11-06T15:11:09","guid":{"rendered":"http:\/\/staging.reviewob.com\/?p=23069"},"modified":"2018-11-13T16:59:50","modified_gmt":"2018-11-13T21:59:50","slug":"how-to-document-for-out-of-pocket-screenings","status":"publish","type":"post","link":"https:\/\/staging.reviewob.com\/how-to-document-for-out-of-pocket-screenings\/","title":{"rendered":"How to Document for Out-of-Pocket Screenings"},"content":{"rendered":"

By Mark Wright, OD, FCOVD,
\nand Carole Burns, OD, FCOVD<\/strong><\/p>\n

\"\"<\/p>\n

Nov. 7, 2018<\/strong><\/p>\n

Screenings that are not covered by patient insurance are becoming more common. Here\u2019s the documentation your practice must do when these screenings take place.<\/p>\n

Screening retinal photographs are a common procedure done in eyecare offices. Screening tests are not medically necessary tests, therefore, cannot be billed to a third party. You can bill the patient, but there are two rules to keep in mind.<\/p>\n

1) Have the patient sign an Advance Written Notice of Non-coverage. In the Medicare world (but these also work for any commercial carrier), pick the form that is most appropriate for the patient you are seeing. These documents are:<\/p>\n

\n

Other Articles to Explore<\/h4>\n
Online Resource That Makes Coding for Medicare Easier<\/span><\/a><\/p>\n

When You Can\u2014and Cannot\u2014Charge an Exam Fee<\/span><\/a><\/p>\n

Glaucoma Screening Codes to Enhance Reimbursements<\/span><\/a>…<\/div>\n<\/div>\n

<\/div>\n

a. Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131<\/p>\n

b. Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Form CMS-10055<\/p>\n

c. Home Health Change of Care Notice (HHCCN), Form CMS-10280<\/p>\n

d. Hospital-Issued Notice of Noncoverage (HINN)<\/p>\n

2) You must explain to the patient and document on the form why the service or procedure is not covered.<\/p>\n

The three most common reasons for non-coverage include:
\n\u2022 When an item or service is considered not medically necessary
\n\u2022 When a service is not indicated for diagnosis and\/or treatment
\n\u2022 When more than the number of services allowed in a specific period for the corresponding diagnosis or treatment occurs<\/p>\n

If, during the screening retinal photo, a medical issue is discovered, the eyecare provider can order a medically necessary retinal photo as long as the new test provides additional information not present in the screening results.<\/p>\n

Some consultants say that this second test can be done on the same day as the screening test. We suggest it is safer to do it on a different day when possible and when waiting does not negatively impact the patient. The concern third parties have is called \u201cbait and switch.\u201d Bait and switch is where you offer a patient a lower fee for a procedure, then you raise the fee on the same visit. For example, the patient is told the screening fee for the retinal photo is $29, but suddenly you\u2019ve billed $79 because you found something and are now calling it a medically necessary retinal photo.<\/p>\n

DOCUMENTATION<\/strong>
\nEven though it is a screening test, you should document the following in your patient\u2019s primary medical record:
\n\u2022 A reference to where the image\/test results are stored
\n\u2022 The patient\u2019s name
\n\u2022 The date of the screening test
\n\u2022 A statement about the results of the screening test
\n\u2022 Your signature<\/p>\n

Remember the documentation rule that if you discover a problem, you must further describe it in words or pictures, and you should include in your primary medical record your impressions, diagnosis and treatment plan for the problem you discovered.<\/p>\n

CODING<\/strong>
\nWhat code should be used for a screening test? You could code S9986 \u2013 payable by the patient. You want to make a notation that the test is \u201cnot medically necessary.\u201d Some carriers will not accept S9986. If the patient insists a claim be filed, then you could report 92250 with a modifier. The modifiers to consider are: GA is expected not to be covered and GZ is unnecessary procedure. (For Medicare, modifier GY is used with 92015 because it is statutorily excluded.)<\/p>\n

You should be aware that some carriers now cover retinal screening photos. When this happens, follow the carrier\u2019s policies exactly.<\/p>\n

Screening tests give the eyecare provider powerful tools to catch problems earlier and, therefore, begin treatment earlier, leading to better outcomes. Follow the rules for screening tests as you utilize these powerful and helpful tools.<\/p>\n

References<\/strong>
\ni. https:\/\/www.cms.gov\/Outreach-and-Education\/Medicare-Learning-Network-MLN\/MLNProducts\/downloads\/ABN_Booklet_ICN006266.pdf<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

By Mark Wright, OD, FCOVD, and Carole Burns, OD, FCOVD Nov. 7, 2018 Screenings that are not covered by patient insurance are becoming more common. Here\u2019s the documentation your practice must do when these screenings take place. Screening retinal photographs are a common procedure done in eyecare offices. Screening tests are not medically necessary tests, therefore, cannot be billed to a third party. You can bill the patient, but there are two rules to keep in mind. 1) Have the patient sign an Advance Written Notice of Non-coverage. In the Medicare world (but these also work for any commercial carrier), pick the form that is most appropriate for the patient you are seeing. These documents are: a. Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 b. Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Form CMS-10055 c. Home Health Change of Care Notice (HHCCN), Form CMS-10280 d. Hospital-Issued Notice of Noncoverage (HINN) 2) You must explain to the patient and document on the form why the service or procedure is not covered. The three most common reasons for non-coverage include: \u2022 When an item or service is considered not medically necessary \u2022 When a service is not indicated for diagnosis and\/or treatment \u2022 When more than the number of services allowed in a specific period for the corresponding diagnosis or treatment occurs If, during the screening retinal photo, a medical issue is discovered, the eyecare provider can order a medically necessary retinal photo as long as the new test provides additional information not present in the screening results. Some consultants say that this second test can be done on the same day as the screening test. We suggest it is safer to do it on a different day when possible and when waiting does not negatively impact the patient. The concern third parties have is called \u201cbait and switch.\u201d Bait and switch is where you offer a patient a lower fee for a procedure, then you raise the fee on the same visit. For example, the patient is told the screening fee for the retinal photo is $29, but suddenly you\u2019ve billed $79 because you found something and are now calling it a medically necessary retinal photo. DOCUMENTATION Even though it is a screening test, you should document the following in your patient\u2019s primary medical record: \u2022 A reference to where the image\/test results are stored \u2022 The patient\u2019s […]<\/p>\n","protected":false},"author":8,"featured_media":23070,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[71],"tags":[1013,41,813,58],"yoast_head":"\nHow to Document for Out-of-Pocket Screenings - Review of Optometric Business<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"How to Document for Out-of-Pocket Screenings - Review of Optometric Business\" \/>\n<meta property=\"og:description\" content=\"By Mark Wright, OD, FCOVD, and Carole Burns, OD, FCOVD Nov. 7, 2018 Screenings that are not covered by patient insurance are becoming more common. Here\u2019s the documentation your practice must do when these screenings take place. Screening retinal photographs are a common procedure done in eyecare offices. Screening tests are not medically necessary tests, therefore, cannot be billed to a third party. You can bill the patient, but there are two rules to keep in mind. 1) Have the patient sign an Advance Written Notice of Non-coverage. In the Medicare world (but these also work for any commercial carrier), pick the form that is most appropriate for the patient you are seeing. These documents are: a. Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 b. Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNFABN), Form CMS-10055 c. Home Health Change of Care Notice (HHCCN), Form CMS-10280 d. Hospital-Issued Notice of Noncoverage (HINN) 2) You must explain to the patient and document on the form why the service or procedure is not covered. The three most common reasons for non-coverage include: \u2022 When an item or service is considered not medically necessary \u2022 When a service is not indicated for diagnosis and\/or treatment \u2022 When more than the number of services allowed in a specific period for the corresponding diagnosis or treatment occurs If, during the screening retinal photo, a medical issue is discovered, the eyecare provider can order a medically necessary retinal photo as long as the new test provides additional information not present in the screening results. Some consultants say that this second test can be done on the same day as the screening test. We suggest it is safer to do it on a different day when possible and when waiting does not negatively impact the patient. The concern third parties have is called \u201cbait and switch.\u201d Bait and switch is where you offer a patient a lower fee for a procedure, then you raise the fee on the same visit. For example, the patient is told the screening fee for the retinal photo is $29, but suddenly you\u2019ve billed $79 because you found something and are now calling it a medically necessary retinal photo. DOCUMENTATION Even though it is a screening test, you should document the following in your patient\u2019s primary medical record: \u2022 A reference to where the image\/test results are stored \u2022 The patient\u2019s […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\" \/>\n<meta property=\"og:site_name\" content=\"Review of Optometric Business\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/reviewob\/\" \/>\n<meta property=\"article:published_time\" content=\"2018-11-06T15:11:09+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2018-11-13T21:59:50+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/reviewob.com\/wp-content\/uploads\/2018\/11\/11-7-18tablet.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"2386\" \/>\n\t<meta property=\"og:image:height\" content=\"1256\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Mark Wright\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@ReviewOB\" \/>\n<meta name=\"twitter:site\" content=\"@ReviewOB\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Mark Wright\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/#article\",\"isPartOf\":{\"@id\":\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\"},\"author\":{\"name\":\"Mark Wright\",\"@id\":\"https:\/\/reviewob.com\/#\/schema\/person\/17e926acbc533883a769a6128244d3f4\"},\"headline\":\"How to Document for Out-of-Pocket Screenings\",\"datePublished\":\"2018-11-06T15:11:09+00:00\",\"dateModified\":\"2018-11-13T21:59:50+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\"},\"wordCount\":647,\"publisher\":{\"@id\":\"https:\/\/reviewob.com\/#organization\"},\"keywords\":[\"documentation\",\"featured\",\"mark wright\",\"practice management\"],\"articleSection\":[\"Coding and Billing\"],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\",\"url\":\"https:\/\/reviewob.com\/how-to-document-for-out-of-pocket-screenings\/\",\"name\":\"How to Document for Out-of-Pocket Screenings - 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The three most common reasons for non-coverage include: \u2022 When an item or service is considered not medically necessary \u2022 When a service is not indicated for diagnosis and\/or treatment \u2022 When more than the number of services allowed in a specific period for the corresponding diagnosis or treatment occurs If, during the screening retinal photo, a medical issue is discovered, the eyecare provider can order a medically necessary retinal photo as long as the new test provides additional information not present in the screening results. Some consultants say that this second test can be done on the same day as the screening test. We suggest it is safer to do it on a different day when possible and when waiting does not negatively impact the patient. The concern third parties have is called \u201cbait and switch.\u201d Bait and switch is where you offer a patient a lower fee for a procedure, then you raise the fee on the same visit. 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