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The new OCT coding and reimbursement guidelines
Part 2 of this series focuses on proper usage of codes for optical coherence tomography.
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 Riva Lee Asbell |
In Part 1 of this series, the basic guidelines for coding and receiving reimbursement for optical coherence tomography in 2011 were covered. Part 2 concentrates on proper usage of the codes so that you are in compliance with Medicare’s rules and regulations. The principal instrument used by Medicare for compliance is the Local Coverage Determination, or LCD.
The codes that are effective Jan. 1, 2011, and replace CPT codes 92135 and 0817T 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
Medical necessity and utilization guidelines
Code descriptor, payment and medical necessity. The code descriptor “unilateral or bilateral” in CPT signifies that it makes no difference whether one or both eyes are tested — the code is to be used one time.
Furthermore, there are medical necessity factors that need to be taken into consideration that determine whether you do one or both eyes for the test. There has to be either clinical findings or symptoms to warrant performing the test. And if there are either findings or symptoms for each eye, then both eyes should be tested. It is totally unacceptable to attempt to obtain reimbursement for each eye by creative scheduling, such as scheduling each eye 6 months apart.
Utilization guidelines and LCDs. Many Medicare contractors have either current or retired LCDs for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) tests. It is imperative that you check this out for your contractor. You will generally find them on your Medicare contractor’s website under Medical Review Policies or a similar name. The policies themselves are generally found under OCT or Scanning Computerized Ophthalmic Diagnostic Imaging. LCDs generally list descriptions of the service, appropriate (and thus eligible for payment) diagnoses, documentation and utilization guidelines. There often is an associated coding and billing document, or that information may be incorporated into the LCD.
The time frame between tests is a function of the disease entity, and guidelines for both glaucoma and retina are provided in the LCDs. It depends on the disease entity and differs for glaucoma, the types of glaucoma and the varying retina diseases. A typical utilization guideline for retina diseases is once every 2 months unless there is active choroidal neovascularization, in which case the test may be reimbursed at monthly intervals.
A sampling of LCDs from various contractors reveals differences, and some contractors have none at all. In many instances, the revisions consist mainly of the substitution of the CPT codes. If your contractor has no policy, it is a good idea to follow the guidelines in one of the other contractor’s LCD, such as Highmark Medicare or NGS Medicare.
The following is from Highmark Medicare:
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
Iris tumor
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.
Certain exceptions that must be determined on a case-by-case basis with the appropriate documentation.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Only two exams/eye/year are allowed for the patient who has or is suspected of having glaucoma.
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.
ICD-9 codes. The ICD-9 diagnosis codes that are eligible for payment are found in the LCD. For retina and glaucoma, assume that the codes that were previously covered and thus eligible for payment will continue to be covered.
In conclusion, there have been many questions, much confusion and significant consternation with the issuance of these codes. Physicians, coders and billers all have been looking for guidance. I hope this two-part series addresses your concerns.
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.
