The test will be performed in the office and then sent for interpretation by an opthamologist. Our office will be billed $ 15 for this service. It is my understanding that the opthamologist does not bill anything to insurance.
Per my research, there are several commercial carriers that will cover this exam. However, CMS deems this test to be routine/screening, unless the patient has already been diagnosed with diabetic retinopathy. So, in most cases, any charge associated with this test would be a Medicare patient’s responsibility (we do plan to have the patient sign ABNs prior to the service being performed).
Per WelchAllyn and my research, the appropriate code for this test would be 92250. Since the interpretation is being billed to our office and not to insurance, we would be billing the global fee. If we are billing to Medicare we would bill using the purchased diagnostic services guidelines.
Reimbursement for this code varies widely between payer… $ 53.51, up to $ 137.31.
I have heard/read that the average fee for this type of exam is around $ 60-$ 75. However, the physicians, at this practice, suggested billing all patients only for the $ 15 that we are being billed for the interpretation and not billing anything to insurance? Is this appropriate?
If not, does anyone have suggestions on how to set up billing? I don’t want to violate Stark Law or create a situation where it could be viewed that we are enticing patients.
Can we completely bypass billing insurance carriers for the service, even though in many cases it is covered?
If we must bill insurance, can we reduce the out-of-pocket expense for Medicare patients because we know that it won’t be covered in most cases? Or can we set our fee at $ 15 for this service, even though that fee is obviously below the average fee?
Obviously, the physicians do not want to burden the patient with much additional out of pocket expense. But, the physicians also believe it is important to do this testing for quality of care of diabetic patients. (They are having a hard time getting patients to see an eye doctor on a regular basis – so believe offering the test in our office would benefit both the physician’s quality data and the patient).
Any help/suggestions on this subject would be greatly appreciated. Also, any references would be great, too.
Thank you!!
Jodi