Coverage Indications, Limitations, and/or Medical Necessity
Medicare will consider scanning computerized ophthalmic diagnostic imaging (SCODI) medically reasonable and necessary in evaluating retinal disorders, glaucoma and anterior segment disorders as documented in this local coverage determination (LCD).
SCODI includes the following tests:
Confocal Laser Scanning Ophthalmoscopy (topography) uses stereoscopic videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina.
Scanning Laser Polarimetry (nerve fiber analyzer) measures change in the linear polarization of light (retardation). It uses both a polarimeter (an optical device to measure linear polarization change) and a scanning laser ophthalmoscope, to measure the thickness of the nerve fiber layer of the retina.
Optical Coherence Tomography (OCT) a non-invasive, non-contact imaging technique.
OCT, especially SCODI, produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of the optic nerve head, nerve fiber layer, and retina.
Scanning computerized ophthalmic diagnostic imaging allows earlier detection of glaucoma and more sophisticated analysis for ongoing management. These tests also provide more precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of time than visual fields and/or disc photos. This allows earlier and more efficient efforts of treatment toward the disease process.
Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma also is diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range.
Glaucoma commonly causes a spectrum of related eye and vision changes, including erosion of the optic nerve and the associated retinal nerve fibers, and also loss of peripheral vision. A diagnosis of glaucoma seldom is made on the basis of a single clinical observation, but instead relies upon analysis of an assemblage of clinical data, including: optic nerve, retinal nerve fiber, and anterior chamber structures, as well as looking for hemorrhages of the optic nerve, pigment in the anterior chamber, and, especially visual field loss. Each of these methods has its own strengths and limitations, thus the dependence upon multiple observations. Careful reliance upon all available clinical data can allow early treatment and can prevent unnecessary end-stage therapies.
Scanning Computer Ophthalmic Diagnostic Imaging (SCODI) allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. Because SCODI detects glaucomatous damage to the nerve fiber layer or optic nerve of the eye, it can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure (IOP). It may separate patients with elevated IOP and early glaucoma damage from those without glaucoma.
Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the optic nerve and nerve fiber layer, even in advanced cases of glaucoma.
It is expected that only two (SCODI) exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma.
Retinal disorders are the most common causes of severe and permanent vision loss. Scanning computerized ophthalmic diagnostic imaging (SCODI) is a valuable tool for the evaluation and treatment of patients with retinal disease, especially macular abnormalities. SCODI is able to detail the microscopic anatomy of the retina and the vitreo-retinal interface. SCODI is useful to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of that therapy.
Retinal thickness analysis is a non-invasive and non-contact imaging technique that takes direct cross-sectional images of the retina. These high resolution images capture ocular structures and provide data to create thickness maps of the retina. Retinal thickness is directly correlated to ocular disease, including retinal disorders and glaucoma. In contrast, Scanning Laser Polarimetry is not an appropriate diagnostic technique for the management of retinal disorders.
Long Term Use of Chlorquine (CQ) and or Hydroxychloroquine (HCQ)
Clinical evidence has shown that long-term use of chloroquine (CQ) and/or hydroxychloroquine (HCQ) can lead to irreversible retinal toxicity. Therefore, these two medications are deemed high risk, and scanning optical coherence tomography may be indicated to provide a baseline prior to starting the medication and as an annual follow-up. Clinical evidence shows that the resolution of time domain OCT instruments is not sufficient to detect early toxic retinal changes. Because of that, spectral domain-optical coherence tomography (SD-OCT) is expected to be used to detect retinal changes that are due to the use of CQ or HCQ.
Anterior Segment Disorders
SCODI may be used to examine the structures in the anterior segment structures of the eye. However, it is still seen as experimental/investigational except in the following:
Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma
Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction
Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber
Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A-scan or IOL master.
The following codes/ procedures would generally not be necessary with SCODI. When medically needed the same day, documentation must justify the procedures.
92250 – Fundus photography with interpretation and report
92225 – Opthalmoscopy extended with retinal drawing (e.g. For retinal detachment, melanoma) with interpretation and report initial
92226 – Subsequent ophthalmoscopy
76512 – B-scan (with or without superimposed non-quantitative A-scan)
Diagnostic Tests, and X-Rays Coding Information
1. Use CPT code(s) 92133 or 92134 to report OCT, include any necessary modifiers (e.g. 26, TC).
1. CPT codes 92133 and 92134 are classified as unilateral or bilateral procedures.
2. Bill the test on a single line, place 00010 in Item 24G on the CMS 1500 claim form or its equivalent.
3. Per CPT guidelines, do not report 92133 and 92134 at the same patient encounter.
4. List the ICD-9 code that best support the medical necessity for the OTC and describes the patient’s condition. ICD-9 code(s) must be present on all Physicians’ Service claims and must be coded to the highest level of accuracy and digit level completeness.
5. *When billing for Spectral Domain-Optical Coherence Tomography (SD-OCT) chloroquine (CQ) and/or hydroxychloroquine (HCQ) for retinal toxicity monitoring, place “SD-OCT) in box #19 to reflect that this form of Optical Coherence Tomography was use.
6. When billing for services, requested by the beneficiary for denial that are Medicare exclusions (i.e. screening) report a screening ICD-9 (V80.2) code and the GY modifier – item or service statutorily excluded or does not meet the definition of any Medicare benefit. A Notice of Exclusion from Medicare Benefits (NEMB) may be used with services excluded from Medicare benefits. See http://www.cms..gov/BNI/01_overview.asp#TopOfPage
7. When billing services, requested by the beneficiary for denial, that would be considered not reasonable and necessary report an ICD-9 code that best described the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier – item or service expected to be denied as not medically necessary when a signed ABN for this service is not on file.
The following situations will result in the denial of the initial diagnostic services or in some cases as a result of a postpayment review
Title XVIII of the Social Security Act section 1862(a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.
1. Services submitted without an ICD-9 code to support medical necessity will be denied as not medical necessity
2. Services billed at excessive frequency will be denied as not medically necessity.
3. Optic disc studies are not to be used as a screening tool for all patients. There must be documented indications from the patient’s exam to justify the medical necessity for testing. Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical checkups and eye examinations and services
4. This service performed for screening purposes or in the absence of associated signs, symptoms, illness or injury will be denied as non-covered.
Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
5. Physicians’ services submitted without an ICD-9 code or not coded to the highest level of accuracy and digit level completeness will be denied as unprocessable.
As you can see, code 92134 in the CPT book is indented under 92133 and simply states “retina,” but it is read as follows: Scanning computer diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina.
• If a code contains the wording “unilateral or bilateral,” then the provider will be paid the same amount whether one or both sides are tested. If there is no “unilateral or bilateral” designation, then Medicare reverts to the bilateral surgery indicator found in the MPFSDB for determination of payment.
• CPT code 92134 indicates “unilateral or bilateral,” meaning that the provider is paid the same amount whether one or both eyes are tested.
• By contrast, CPT code 76512 reads: Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed nonquantitative A-scan). This code does not specify “unilateral or bilateral,” and it is paid according to the indicator in the MPFSDB. The indicator is 3, signifying that each side will be paid 100% of the Medicare fee schedule allowed amount for that code.
The CPT description for OCT (92134) for the retina was given above in the discussion of “unilateral or bilateral.” It does contain the phrase “unilateral or bilateral,” with a bilateral surgery indicator of 2, and it is therefore billed only once regardless of whether one or both sides are tested. Do not use modifier 52 when only one side is tested. Caution is also warranted when billing fundus photography in lieu of OCT because age-related macular degeneration treatment is based on the results of OCT; thus, it is OCT, not fundus photography, for which there is medical necessity
92134-Scanning Computerized Ophthalmic Dagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
* Retinal disorders are most common causes of severe and permanent vision loss. These technologies are valuable tools for evaluation and treatment of patients with retinal disease, especially macular abnormalities.
* These imaging techniques are useful tools to measure effectiveness of therapy, and in determining need for ongoing therapy, or safety of cessation of therapy.
92134-Scanning Computerize Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
* Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease
* One exam/eye/month is allowed for the patient who is undergoing active treatment for macular degeneration or diabetic retinopathy
Ganglion Cell Analysis-92134 Isolates Ganglion Cell Layer
• Measures thickness for sum of GCL and IPL layers using data from Macular cube scans.
• RNFL distribution in the macula depends on individual anatomy, while the GCL+IPL appears regular and elliptical for most normal individuals
Propriety algorithms are adapted for specific anatomy, use GCL and IPL thickness
Fundus Photography & SCODI
* There has been no specific document defining when you can use 92133 and 92134 with 92250
* This means there is no official CMS guidance on using “mutually exclusive” codes on the same date of service.
National Correct Coding Initiative (NCCI) • Developed with RBRVS- 2003
• Insures proper Medicare payments (Resource Based Relative Value System)
• Identify pairs of services not billed together (same physician for same patient on same day)
• Component element edits
o 92012 and 92014
• Medically Unlikely Edits (MUE) policy manual
o 92133 or 92134 and 92250 but MAY use -59 modifier
o 92133 and 92134 may NOT be used together even with -59 modifier
NCCI Edits Relevant to Optometry
* Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (e.g., CPT codes 92132, 92133, 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to CPT code 92250. (CPT code 92135 was deleted January 1, 2011.)
*CPT code 92071 (fitting of contact lens for treatment of ocular surface disease) should not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea.
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
C69.01 Malignant neoplasm of right conjunctiva
C69.02 Malignant neoplasm of left conjunctiva
C69.11 Malignant neoplasm of right cornea
C69.12 Malignant neoplasm of left cornea
C69.21 Malignant neoplasm of right retina
C69.22 Malignant neoplasm of left retina
C69.31 Malignant neoplasm of right choroid
C69.32 Malignant neoplasm of left choroid
C69.41 Malignant neoplasm of right ciliary body
C69.42 Malignant neoplasm of left ciliary body
C69.51 Malignant neoplasm of right lacrimal gland and duct
C69.52 Malignant neoplasm of left lacrimal gland and duct
C69.61 Malignant neoplasm of right orbit
C69.62 Malignant neoplasm of left orbit
C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa
D31.01 Benign neoplasm of right conjunctiva
D31.02 Benign neoplasm of left conjunctiva
D31.11 Benign neoplasm of right cornea
D31.12 Benign neoplasm of left cornea
D31.21 Benign neoplasm of right retina
D31.22 Benign neoplasm of left retina
D31.31 Benign neoplasm of right choroid
D31.32 Benign neoplasm of left choroid
D31.41 Benign neoplasm of right ciliary body
D31.42 Benign neoplasm of left ciliary body
D31.51 Benign neoplasm of right lacrimal gland and duct
D31.52 Benign neoplasm of left lacrimal gland and duct
D31.61 Benign neoplasm of unspecified site of right orbit
D31.62 Benign neoplasm of unspecified site of left orbit
D31.91 Benign neoplasm of unspecified part of right eye
D31.92 Benign neoplasm of unspecified part of left eye
H16.001 Unspecified corneal ulcer, right eye
H16.002 Unspecified corneal ulcer, left eye
H16.003 Unspecified corneal ulcer, bilateral
H16.011 Central corneal ulcer, right eye
H16.012 Central corneal ulcer, left eye
H16.013 Central corneal ulcer, bilateral
H16.021 Ring corneal ulcer, right eye
H16.022 Ring corneal ulcer, left eye
H16.023 Ring corneal ulcer, bilateral
H16.031 Corneal ulcer with hypopyon, right eye
H16.032 Corneal ulcer with hypopyon, left eye
H16.033 Corneal ulcer with hypopyon, bilateral
H16.041 Marginal corneal ulcer, right eye
H16.042 Marginal corneal ulcer, left eye
H16.043 Marginal corneal ulcer, bilateral
H16.051 Mooren’s corneal ulcer, right eye
H16.052 Mooren’s corneal ulcer, left eye
H16.053 Mooren’s corneal ulcer, bilateral
H16.061 Mycotic corneal ulcer, right eye
H16.062 Mycotic corneal ulcer, left eye
H16.063 Mycotic corneal ulcer, bilateral
H16.071 Perforated corneal ulcer, right eye
H16.072 Perforated corneal ulcer, left eye
H16.073 Perforated corneal ulcer, bilateral
H18.11 Bullous keratopathy, right eye
H18.12 Bullous keratopathy, left eye
H18.13 Bullous keratopathy, bilateral
H18.20 Unspecified corneal edema
H18.211 Corneal edema secondary to contact lens, right eye
H18.212 Corneal edema secondary to contact lens, left eye
H18.213 Corneal edema secondary to contact lens, bilateral
H18.221 Idiopathic corneal edema, right eye
H18.222 Idiopathic corneal edema, left eye
H18.223 Idiopathic corneal edema, bilateral
H18.231 Secondary corneal edema, right eye
H18.232 Secondary corneal edema, left eye
H18.233 Secondary corneal edema, bilateral
H18.50 Unspecified hereditary corneal dystrophies
H18.51 Endothelial corneal dystrophy
H18.711 Corneal ectasia, right eye
H18.712 Corneal ectasia, left eye
H18.713 Corneal ectasia, bilateral
H18.721 Corneal staphyloma, right eye
H18.722 Corneal staphyloma, left eye
H18.723 Corneal staphyloma, bilateral
H18.731 Descemetocele, right eye
H18.732 Descemetocele, left eye
H18.733 Descemetocele, bilateral
H40.021 Open angle with borderline findings, high risk, right eye
H40.022 Open angle with borderline findings, high risk, left eye
H40.023 Open angle with borderline findings, high risk, bilateral
H40.031 Anatomical narrow angle, right eye
H40.032 Anatomical narrow angle, left eye
H40.033 Anatomical narrow angle, bilateral
H40.061 Primary angle closure without glaucoma damage, right eye
H40.062 Primary angle closure without glaucoma damage, left eye
H40.063 Primary angle closure without glaucoma damage, bilateral
H40.1110 Primary open-angle glaucoma, right eye, stage unspecified
H40.1111 Primary open-angle glaucoma, right eye, mild stage
H40.1112 Primary open-angle glaucoma, right eye, moderate stage
H40.1113 Primary open-angle glaucoma, right eye, severe stage
H40.1114 Primary open-angle glaucoma, right eye, indeterminate stage
H40.1120 Primary open-angle glaucoma, left eye, stage unspecified
H40.1121 Primary open-angle glaucoma, left eye, mild stage
H40.1122 Primary open-angle glaucoma, left eye, moderate stage
H40.1123 Primary open-angle glaucoma, left eye, severe stage
H40.1124 Primary open-angle glaucoma, left eye, indeterminate stage
H40.1130 Primary open-angle glaucoma, bilateral, stage unspecified