95930_R26

1.   All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.

2.  Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The documentation must include the legible signature of the optometrist or ophthalmologist responsible for and providing the care to the patient.

3.  The submitted medical record must support the use of the selected ICD-10-CM code(s).  The submitted CPT/HCPCS code must describe the service performed.

4.  The medical record documentation must support the medical necessity of the services as directed in this policy.

5.  The patient’s medical record must contain documentation that fully supports the medical necessity for NEPs as covered by Medicare.  This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.

1.  Report a VEP with CPT code 95930.  This is a bilateral test, therefore no modifiers are required if both eyes are examined.  A unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.

2.  A VEP test is usually reported globally, but it may be separated into a professional component (modifier -26 and a technical component (modifier -TC) if necessary.

3.  VEP test can be done with general or direct supervision by the optometrist/ophthalmologist depending on if the technician is certified or non-technicians are now able to become certified by the American Board of Physical Therapy Specialties (ABPTS) to perform sensitive and complex neurophysiological studies.  If your technician is certified, a VEP test may be performed under general supervision (the doctor is not immediately available).  If your technician is not ABPTS certified, a VEP test must be performed with direct supervision (doctor is immediately available).

4.  An eye examination may be reported on the same day as a visual evoked potential test if it is medically necessary.

In general, VEP testing is reimbursed when it is reasonable and medically necessary.  Since there are no published utilization guidelines for VEP testing, doctors should adhere to CMS Ruling 95-1 (V) which states that utilization of VEP testing should be consistent with locally acceptable standards of practice.

According to the International Society for Clinical Electrophysiology of Vision, a minimum of two VEP recordings should be acquired, measured, and displayed to confirm the reproducibility of data if the findings are abnormal.  Also, it is usually not medically necessary to perform more than two VEP tests in a twelve-month period to diagnose and treat optic nerve disease.

Amerigroup – Clinical Guideline

Description

Visual evoked potentials (VEPs)This document addresses non-operative uses of the following evoked potential (EP) studies:

Evoked potentials (EPs) or evoked responses are electrical waves created in the central nervous system by peripheral stimulation of a sensory organ. EPs are used to identify abnormal central nervous system function that may not be detected clinically.

Clinical Indications

Multiple sclerosis or neuromyelitis optica (NMO), or other demyelinating disorders of the optic nerve;orVisual evoked potentials (VEPs) are considered medically necessary for the diagnosis, evaluation, or monitoring of any of the following conditions:

• Suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by MRI, CT, infectious diseases or metabolic disorders.

Visual evoked potentials (VEPs) are considered not medically necessary for all other uses, including but not limited to routine screening of infants.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

ICD-10 Diagnosis Codes

ICD-9 Diagnosis Codes

Discussion 

EPs are recordings of the nervous system’s electrical response to the stimulation of specific sensory pathways. These recordings have the ability to provide information relative to the functional integrity of pathways within the nervous system. Only a few EPs are used on a routine basis and those most frequently encountered include VEPs and SSEPs.

Visual Evoked Potentials (VEPs)

VEPs track signals from the retina to the visual cortex and determine how a visual system reacts to light. A common indication for VEPs is to help confirm the diagnosis of MS, or to evaluate and monitor MS. In general, myelin plaques which occur in MS slow the speed of VEP wave peaks. Over time VEPs in individuals with MS become progressively slower eventually attenuating in amplitude as demyelination increases (Creel, 2012). The American Academy of Neurology (AAN) (Gronseth, 2000) recommends VEPs as probably useful to identify those at increased risk for clinically definite MS.

VEPs have also been used for other conditions including neuromyelitis optica (NMO) or other demyelinating disorders of the optic nerves, or for a suspected disorder of the optic nerve, optic chiasm or optic radiations not explained by magnetic resonance imaging (MRI), computerized tomography (CT), infectious diseases or metabolic disorders.

The U.S. Preventive Services Task Force (USPSTF) (2011) has not recommended vision screening for infants and young children. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children less than 3 years of age.