Reimbursement Procedures and Best Practices for Quantitative Pupillometry

Basis of Evaluation

Utilizing the pupillary light reflex is an invaluable tool to assess for autonomic function testing. This is because the pupillary constrictor muscle is innervated by CNIII, which also responds to sympathetic responses and catecholamine release. We have utilized it in the office as a supportive test for neurological function. Common conditions we utilize this test for include closed head trauma, TIA/stroke, dysautonomia (POTS, rapid resting heart rate, exercise intolerance, among others), and other functional neurological disorders (FND).

Covid-19 produces functional neurological disorders, triggering dysautonomia with changes in heart rate, respiration, and cardiovagal innervation. Commonly, cardiovascular symptoms persist post-infection, along with poor vagal tone. This change in tone can be visualized with an enlarged pupil. Practitioners across the board must become familiar with post-Covid syndromes; this is a quick and efficient tool to do so.

Passport 2 Health uses this with oculomotor testing for closed-head injury assessments of post-motor vehicle accidents. Drs. Carrick and Azzolino identified four specific parameters within the PLR that serve as biomarkers for neurological function, demonstrating sensitivity to traumatic brain injury.

CPT Code 95919 — Quantitative Pupillometry

We selected this ICD-10 code for neurological autonomic function testing. This code is used for both the testing and the interpretation. Reimbursement approval from AAA for personal injury claims ranges from $50 to $100 per test.

To submit for Medpay via CMS 1500 form: add the patient's demographics, service date, and CPT code, then submit to the insurance carrier. Additional materials include SOAP notes with explanations or interpretations of test results. It is advisable to establish a relationship with an insurance adjuster where possible.

In-Clinic Procedure

Inpatient testing

• Have a clinician or tech administer the test
• Once completed, verify the test, interpret the results, and record — the Interpretation and Report (I&R) notes must be entered into the Reflex Notes section with the observed diagnosis
• This can be done within the Reflex App or post-admin in the Reflex Web Portal Notes section under the patient test record
• Print a PDF document including the notes and applicable I&R report for the patient file

Remote testing via Reflex Telehealth

• Have the clinician or CA send remote test access to the patient through the Reflex Web Portal
• Use the Reflex Web Portal to monitor patients remotely
• Once the remote test is complete, verify, interpret, and record results in the Reflex Web Portal
• Export a PDF report to be logged with the patient file

Personal Experience

I purchased a mobile quantitative pupillometer from Reflex in February 2022, which proved to be one of the best modalities and decisions I have made in practice. At the time, I was catastrophically injured and not receiving disability despite paying into a private long-term disability policy. My Reflex pupillometer — along with other objective testing performed in the office — turned into my backup disability financial plan. I was hospitalized off and on for four months and unable to walk, yet my office doors were still open and providing a valuable service to patients.

I was also able to monitor and diagnose my impending stroke and no less than six other patients during the two years of barely ambulatory disability. In California, there was an exceptional need for neurological services during COVID-19 yet access to care was deplorable. Three of my patients' strokes were able to be rehabilitated through chiropractic functional neurology before they even saw their neurologist.