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Reimbursement for Electrophysiology Testing

Topic: Electrophysiology

Sponsor: Corcoran Consulting Group

Updated: 06/22/2018

Corcoran Consulting Group

Some patients visit an ophthalmologist or optometrist with complaints that cannot be readily diagnosed by clinical exam or common ophthalmic diagnostic tests. The optic nerve or the cells within the retina may be the source of the problem(s) and electrophysiology testing can facilitate a diagnosis when other testing is unreliable or inconclusive.

This monograph describes reimbursement for electrophysiology tests including visual evoked potential (VEP), electroretinogram (ERG), and electro-oculography (EOG), either alone or as part of another service. Much of the information is taken from official publications of the Medicare program, including the Centers for Medicare & Medicaid (CMS) and the Medicare Administrative Contractors (MAC). The reader is encouraged to check with the local MAC for additional information and instructions. In the case of other third party payers, we have used the coding concepts contained in CPT and published by the American Medical Association; diagnosis codes are from ICD-10-CM. Documentation of the medical necessity of the procedure is a prerequisite to reimbursement, so we describe the required elements in detail.

Since economic analyses are a necessary part of any capital budgeting decision, we incorporated Medicare’s payment rates as well as utilization rates.