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Eye care providers should evaluate an in-office lab test or any procedure to gauge its impact on patient care.
Editor’s Note: This is the second installment of a two-part series.
ead the first installment here: Lab tear tests aid reimbursements, clinical application of dry eye
Eye-care specialists are quickly adopting in-office diagnostics including in vitro diagnostic, or laboratory, point-of-care tests to analyze tear fluid as front-line tools to triage refractive and refractive cataract patients.
To help further clarify use and payment of these tests, the second part of this article discusses how the tests are implemented in practice and how reimbursement is determined.
OD ALERT: LAB TESTS ARE BILLED TO MEDICAL INSURANCE
Osmolarity and MMP-9 tests bill as a laboratory, pay under the laboratory fee schedule and always from the patient’s medical insurance. Although ocular surface disease (OSD) has an impact on both vision and medical care, in either case, laboratory testing will be billed under the medical plan-a standard practice for most MDs.
Optometrists, on the other hand, may be performing laboratory tests during a vision visit. Although the eye-care provider cannot conduct a medical and vision exam on the same day, he or she can perform and bill for a laboratory test during a vision visit. The vision visit is billed to the vision plan and the laboratory test to the patient’s medical plan.
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During the vision exam, if the patient indicates symptoms on a dry eye questionnaire, the provider can perform and bill a lab tear test on the same day to confirm or rule out dry eye disease. If the patient has hyperosmolarity or abnormal MMP-9 and OSD is suspected, the patient can be rescheduled for a follow-up visit.
If a patient presents with dry eye symptoms during a vision exam, he or she should be informed that laboratory testing is recommended and discuss how OSD can have a negative impact on vision.
Patients making a significant financial investment in cataract or refractive surgery, eyeglasses, or premium contact lenses should have the most accurate diagnostic data, refraction, and prescription possible to prevent refractive “surprise.”
Staff should alert the patient that to ensure optimal outcome, a lab test will be performed and billed under their medical insurance, which may require an unanticipated out-of-pocket copayment.
Patients visiting an ophthalmologist’s office are usually older with the visit typically related to a medical problem-often under Medicare. If the patient is under Centers for Medicare and Medicaid Services (CMS) Medicare Part B, CMS will pay 100% of all lab tests to the provider with no patient copay or deductible, making it seamless with no financial impact to the patient. CMS currently pays $22.48 for each eye for the TearLab Osmolarity test (CPT 83861) in all 50 states.
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CMS assesses appropriate payment for new laboratory CPT codes at an annual public meeting held every July. During this process, stakeholders, including manufacturers, physicians, or the pertinent clinical society, provide information regarding the type of technology, time, resources and cost involved to perform the test. The new test is compared to an existing, similar test on the Clinical Laboratory Fee Schedule.
Once an existing and comparable test is identified, the new test is given the same reimbursement as is being paid for the existing test. This crosswalk process is usually considered fair and equitable by both CMS and the stakeholders.
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Commercial payers do not have such a process, however, and historically have adopted the CMS laboratory fee schedule’s rates. There is a caveat. The vast majority of laboratory tests are performed by a few large reference laboratories, such as Quest and LabCorp.
Because of this discount, insurance companies prefer and may require patients to only be tested at the reference laboratory. If a doctor’s office wishes to perform lab tests in the office, the insurance company will usually allow it, but only at the same discounted reimbursement they pay the contracted lab.
Tear fluid tests, however, such as osmolarity and MMP-9, can never be performed at an outside lab because the fluid sample is too small and fragile to transport. As pricing is dictated in the provider contract, each doctor would have to address a change in the contract on a case-by-case basis in order to “carve-out” special pricing for testing tear fluid samples.
TearLab’s Reimbursement Support team can help with reimbursement issues for osmolarity testing, as it regularly interfaces with insurance companies on behalf of customers. Though not easy, renegotiating can be discussed on a case-by-case basis.
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Eye-care providers should first evaluate an in-office lab test or any other diagnostic procedure based on its clinical value and its impact on patient care in their practice. Once clinical value is established, economics can be assessed.
Osmolarity and MMP-9 are now included in several professional groups’ clinical guidelines for the diagnosis and management of dry eye and OSD, providing justification for payers to reimburse these tests appropriately.
The SjÃ¶gren’s Syndrome Foundation recommends osmolarity testing as an advanced method to diagnosis and monitor a patient’s response to therapy,1 and the American Academy of Ophthalmology’s Preferred Practice Pattern indicates that osmolarity is an earlier indicator of clinical signs of dry eye,2 not inconsequential for a disease that may take three to six months of treatment to fully resolve.
Finally, as highlighted in part 1 of this article, the American Society of Cataract and Refractive Surgery’s algorithm considers osmolarity and MMP-9 tests essential for pre-diagnostic assessments, ultimately stating that patients with visually significant disease should not proceed with cataract surgery.3
Michael Berg is vice president of regulatory and reimbursement, TearLabCorp.
1. Foulks GN, Forstot SL, Donshik PC. Clinical guidelines for management of dry eye associated with Sjogren disease.
The Ocular Surface. 2015:13:118-132.
2. Akpek EK, Amescua G, Farid M, et al. on behalf of the American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Dry Eye Preferred Practice Pattern. Ophthalmol. 2019;126(1):P286-P334. https://doi.org/10.1016/j.ophtha.2018.10.023.
3. Starr CE, Gupta PK, Farid M, et al; ASCRS Cornea Clinical Committee. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669-684. doi: 10.1016/j.jcrs.2019.03.023.