Medical and/or Vision Insurance plans do not cover the Specialty Dry Eye Testing or LipiFlow services.
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- Jeffrey Hudson
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1 ADVANCED BENEFICIARY NOTICE (ABN) Patient s Name: Date of Birth: The purpose of this form is to help you make an informed choice about your visit today. Before you make a decision about your options, you should read this entire notice carefully. Medical and/or Vision Insurance plans do not cover the Specialty Dry Eye Testing or LipiFlow services. You will be responsible for 100% of all fees for each procedure. The following items are NOT covered by any insurance. You are responsible for these charges: Items or Services: Cost: Specialty Dry Eye Testing $ LipiFlow Both Eyes $ I have read and understand the above statement and agree to pay for all services, and understand that my insurance will not be billed for the procedures listed above. Preliminary and aftercare follow-up visits can be billed to insurance will be billed. I am responsible for any copays and co-insurance and understand that any amounts billed can be applied towards deductibles. Specialty Dry Eye Testing Signature: Date: LipiFlow Signature: Date:
2 INSURANCE ELIGIBILITY DETAILS FOR THE FDA APPROVED LIPIFLOW THERMAL PULSATION PROCEDURE The information below provides an overview of the coding and insurance billing for treatment of: Meibomian Gland Dysfunction Disease (MGD) and Evaporative Dry Eye & Blepharitis with FDA approved LipiFLOW Thermal Pulsation Procedure (CPT Code 0207T). Insurance Coverage: LipiView & LipiFlow are Non-Covered Services. As we are preferred Providers for many insurance carriers, we have confirmed LipiView Surface Imaging and LipiFlow Thermal Pulsation Procedure are not covered services per current insurance guidelines and general medical provider contracts. Therefore, Specialty Eyecare Group will not bill the insurance carrier, request a pre-certification or prior-authorization regarding LipiView or LipiFlow treatment as this is deemed inappropriate by both parties given established non-coverage status. LipiView Surface Imaging and LipiFlow Thermal Pulsation Procedure are categorized as elective services. Overall, this means Insurance carriers do not recognize either LipiView diagnostic or LipiFlow treatment and will not pay or cover service fees. Patients choosing to have LipiView and/or LipiFlow are financially responsible for their service and treatment fees (see fees below). Checking For Your Plan s Coverage: Upon checking personal benefits and coverage for LipiView and LipiFlow with your insurance Customer Service Representatives for insurance carriers are required to respond to elective treatments, or procedures, without established coverage or reimbursement with request for prior authorization, a referral, or precertification with chart notes or clinicals. Prior-Authorizations WILL NOT be submitted by Specialty Eyecare Group due to established non-coverage of the elective medical services for LipiView and LipiFlow. Regardless, these submissions WILL NOT change the status of non-covered services to a covered service. Patients wishing to submit treatment services to their insurance carrier may do so, however, it is Specialty Eyecare Group policy that we WILL NOT submit elective treatment billing with non-established benefits under any circumstance. Therefore, Insurance will not be billed by Specialty Eyecare Group for elective testing and treatment/services given non-coverage status. Fees for LipiView testing and/or LipiFlow treatment are collected on the day of service. Patients may choose to personally submit their treatment information and clinicals to their providers. Documentation will be made available to requesting patients. Methods of Payment: Cash, Check, Credit Cards: Mastercard, Visa HSA & Flexible Spending Eligible: You may choose to use your pre-tax flexible spending funds or health savings account for LipiView and LipiFlow services. Diagnosis Codes: Evaporative Dry Eye: code Blepharitis (inflammatory meibomian gland lid condition): code Treatment codes: CPT Code: 0330T LipiView: Tear film imaging, unilateral or bilateral, with interpretation and report. $ CPT Code: 0207T LipiFlow: Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral. Single: $ Both Eyes: $ Insurance coding: LipiFlow is categorized with a level III (3) CPT Code. Category 3 CPT codes are temporary codes and automatic denial. Category 3 codes are used to represent emerging services and procedures like FDA approved LipiFlow. Please sign below to acknowledge that you have read and understand this form. Signature Date
3 David L. Kading, OD, FAAO, FCLSA Kristi Kading, OD, FAAO, FCOVD Katherine Shen, OD Charissa Young, OD Patient Name: Date: - - Dry Eye Questionnaire How frequently do you experience any of these dry eye symptoms? Never Sometimes Often Constant Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue How severe are your dry eye symptoms? No problems Tolerable Uncomfortable Bothersome Intolerable Unable to perform my daily tasks Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue IN OFFICE USE ONLY BELOW SEG DEQ (SPEED) Score Meiboscale: OD: 0 = 0% 1 = 25% 2 = 25-50% 3 = 50-75% 4 = % NE 128 th St. Suite 1, Kirkland, WA th Ave, Seattle, WA p / f p / f
4 David L. Kading, OD, FAAO, FCLSA Kristi Kading, OD, FAAO, FCOVD Katherine Shen, OD Charissa Young, OD OS: 0 = 0% 1 = 25% 2 = 25-50% 3 = 50-75% 4 = % NE 128 th St. Suite 1, Kirkland, WA th Ave, Seattle, WA p / f p / f
5 Ocular Surface Disease Index (OSDI ) 2 Ask your patient the following 12 questions, and circle the number in the box that best represents each answer. Then, fill in boxes A, B, C, D, and E according to the instructions beside each. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK: 1. Eyes that are sensitive to light? Eyes that feel gritty? Painful or sore eyes? Blurred vision? Poor vision? Subtotal score for answers 1 to 5 (A) HAVE PROBLEMS WITH YOUR EYES LIMITED YOU IN PERFORMING ANY OF THE FOLLOWING DURING THE LAST WEEK: 6. Reading? N/A 7. Driving at night? N/A 8. Working with a computer or bank machine (ATM)? N/A 9. Watching TV? N/A Subtotal score for answers 6 to 9 HAVE YOUR EYES FELT UNCOMFORTABLE IN ANY OF THE FOLLOWING SITUATIONS DURING THE LAST WEEK: 10. Windy conditions? N/A 11. Places or areas with low humidity (very dry)? N/A 12. Areas that are air conditioned? N/A (B) Subtotal score for answers 10 to 12 (C) ADD SUBTOTALS A, B, AND C TO OBTAIN D (D = SUM OF SCORES FOR ALL QUESTIONS ANSWERED) TOTAL NUMBER OF QUESTIONS ANSWERED (DO NOT INCLUDE QUESTIONS ANSWERED N/ A) (D) (E) Please turn over the questionnaire to calculate the patient s final OSDI score.
Welcome Packet New Patient
Hello, We excited to welcome you to Southern Eye Associates. It is a pleasure having the opportunity to begin taking care of your eye health. ur practice and providers have had the opportunity to take
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