CPT coding changes restrict OCT reimbursements

Part 1 of this series focuses on basic guidelines regarding the revised codes for optical coherence tomography.

Riva Lee Asbell

With the advent of a new and revised coding system for the diagnostic tests collectively known as Scanning Computerized Ophthalmic Diagnostic Imaging, or SCODI, a barrage of questions has emerged amidst confusion. This review addresses these issues regarding optical coherence tomography and pertains to Medicare only. Other insurers are making independent decisions and may be slow in their implementation. Each insurer should be contacted directly.

History and 2011 code changes

The Current Procedural Terminology code for SCODI was originally developed as a glaucoma diagnostic test. Retina diagnosis usage and codes were added to the coverage, and finally, in 2011, anterior segment diagnoses were given a Category I CPT code, raised from a Category III code (0187T).

The codes involved, effective Jan. 1, 2011, from the 2011 CPT, are:

92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral

92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

92134 retina

Note that in CPT when a code such as 92134 is indented, the code description from the preceding non-indented code up to the semicolon is included in the code description. Thus, 92134 technically reads:

92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

The CPT codes formerly used (92135 and 0187T) can only be used for services provided up to Dec. 31, 2010, for Medicare. Other insurers are in the process of making determinations on reimbursement for this.

The impetus that drove the Centers for Medicare and Medicaid Services to make these changes involved utilization and payment issues.

Payment issues

The national average payment for the procedures is as follows:

92132 = $36.35

92133 = $44.51

92134 = $44.51

The fee is paid only once whether one or both eyes are tested. The significant change from the old CPT code 92135 to the new codes (92132, 92133 and 92134) is that SCODI is now paid once for both sides whereas it was formerly paid for each side. This effectively halved the payment for the test when it is performed bilaterally.

Modifiers

Technically, no modifiers are required for this test. It is possible that Medicare contractors may require them in the future. Be guided by your Local Coverage Determination. You do not need to use modifier 52 (reduced services) when performing the test on one eye. Ordinarily if a test is deemed bilateral on the Medicare Physician Fee Schedule Database, such as fundus photos, and is only performed on one side of paired organ systems, then modifier 52 should be applied. However, in this case the descriptor of unilateral or bilateral negates that.

CPT instructions and NCCI bundles

CPT instructions after the codes in the 2011 book state:

“(Do not report 92133 and 92134 at the same patient encounter)”

“(92135 has been deleted)”

“(for scanning computerized ophthalmic diagnostic imaging of the optic nerve and retina, see 92133, 92134)”

In version 17.0 of the National Correct Coding Initiative (NCCI), the obvious occurred, and 92133 and 92134 were bundled. However, the modifier indicator is “0,” meaning that you cannot use modifier 59 to break the bundle under any circumstances.

Thus, there are the following code edit pairs:

92134 – 92132

92133 – 92132

92134 – 92133

The first and second code edit pairs have a modifier indicator of 1, which means under appropriate circumstances the edit can be broken by using modifier 59. I would advise against doing that with the exception of the test being performed for a condition in one eye (eg, wet macular degeneration) and the other test being performed for a condition in the fellow eye (eg, anterior segment anomaly).

Remember, the code pair edits apply only to services performed on the same date of service.

Fundus photo NCCI bundles

The origin of the fundus photo bundles with SCODI dates back to when the code was first developed. Many practices were billing for both tests but not actually performing separate fundus photos; they were merely part of the SCODI test (a recreation of the optic nerve). Do not unbundle them unless your Medicare contractor specifies that it is allowed. A draft policy that does is currently posted for First Coast Service Options in Florida. It remains to be seen whether it is put into effect or not.

Fundus photos (CPT code 92250) and OCT for retina (CPT code 92134) are bundled mutually exclusively in the NCCI. The national average payment for fundus photos is $73.38 and for OCT retina is $44.51.

If both are coded together, the lowest-paying one is paid. If both fundus photos and OCT are medically necessary, technically you can bill only for the fundus photos; however, I caution you to be absolutely certain additional information is gained from each test. For those patients with choroidal neovascularization, for example, who have OCT scans done in conjunction with the determination of whether an injection should be performed or for monitoring the test, then the test that should be billed is the OCT.

In Part 2, we will look at Medicare compliance issues and following your Medicare Administrative Contractor’s Local Coverage Determinations.

Reference:

• CPT codes copyright American Medical Association 2011.

• Riva Lee Asbell is president of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm, and a clinical assistant professor of surgery (ophthalmology) at the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School at Camden. She can be reached at RivaLee@aol.com; website: www.RivaLeeAsbell.com.

The discontinuation of CPT 92135 and the inauguration of three replacement codes (92132, 92133, 92134) is a significant change for ophthalmologists and optometrists. It was not unexpected. The volume of testing with SCODI has grown rapidly during the past dozen years and will likely continue to grow after the anticipated precipitous drop in 2011 since per eye billing stopped. Postpayment audits for prior claims will likely escalate due to aggressive billing, particularly the misuse of modifier -59 with fundus photography. Payments will decrease due to the change to “unilateral or bilateral” in the description. Finally, new policies will be written for each CPT code to replace the old policy for 92135 and, thereby, clarify coverage and payment rules for different indications.

– Kevin J. Corcoran, COE, CPC, FNAO
President, Corcoran Consulting Group
San Bernardino, Calif.
Disclosure: No products or companies are mentioned that would require financial disclosure.