New year brings major changes in Medicare coding for diagnostic imaging

Code 92135 has been replaced with three separate codes for 2011.

Charles B. Brownlow

Just as your new diagnostic imaging instrument is delivered and you are feeling good about the great discount you got and the break it provided for your 2010 income taxes, your 2011 edition of Current Procedural Terminology (CPT, American Medical Association) shows up in your mailbox.

As is your habit, you open it up and turn immediately to the Medicine Guidelines section of the book to check the definitions for all the ophthalmology series (92000) codes. You carefully read through the General Ophthalmological Services, find no significant changes and then begin reading each of the definitions in the Special Ophthalmological Services section.

You start with “92015, determination of refractive state;” no change there. You proceed down through “92020, gonioscopy;” no change. You continue through “92060, sensorimotor examination,” “92081-92083, visual field examination,” “92100, serial tonometry,” “92132, scanning…” Where is 92135? What’s going on here?

The code 92135 has been replaced with three separate codes for 2011. The change occurred through the CPT Editorial Board over the course of several meetings, as part of a systematic, periodic review of all CPT codes.

You may remember that anterior segment imaging came on the scene within the last few years and had been given a Category III CPT code (a temporary code), 0187T. The Editorial Board needed to decide whether to give anterior segment imaging a Category I code and, in the process, it reconsidered the appropriateness of 92135. “Anterior segment imaging” was given the code 92132, “imaging of the posterior retina, optic nerve” was given a new code, 92133, and “imaging of the posterior segment, retina” was given the code 92134.

‘Bilateral’ now ‘unilateral’

After the decision to eliminate 92135 and replace it with 92132 through 92134, the CPT Editorial Board also decided to change the code from “unilateral,” billed on a per-eye basis, to “unilateral or bilateral,” meaning that the reimbursement is the same whether the test is done on one eye or both. Even though 92135 was unilateral, most other services in the Special Ophthalmological Services series are bilateral. This trend of changing unilateral services to bilateral goes back a long way in eye care, as visual fields were originally unilateral codes and have been bilateral for about 20 years.

Source: Brownlow CB

One would assume that changing a code from unilateral to bilateral is a reflection of the Editorial Board’s understanding that the service is generally done on both eyes at the same visit, based on its review of claims data. The change would not be significant on its own if the resulting value for the service was at or near two times the value set for the service unilaterally.

Unfortunately, that is not what happened. The relative value for each of the new codes and, thus, the Medicare allowed charge for two eyes is very close to the 2010 Medicare allowed charge for 92135 for each eye.

The relative value unit and allowed charge for each of the new codes are shown in the accompanying table.

Updating the relative value scale

Setting the relative values for new codes and reviewing the relative values of existing codes is the responsibility of another board, the AMA Relative Value Scale Update Committee (RUC), which comprises representatives from the various specialties, including optometry and ophthalmology.

The relative value for each code is based upon several factors, including practice expense, physician work and professional liability expense. All deliberations of the CPT Editorial Board and the RUC are confidential, so any theories regarding the logic applied to the act of setting these values would be pure conjecture.

Changes to posterior codes

According to the 2011 CPT, the two posterior codes, 92133 and 92134, are mutually exclusive and cannot be reported on the same day. However, either of the two may be reported on the same day 92132 is done, assuming the diagnosis codes support their use. The appropriate use of each of these codes is based on the needs of the patient, of course, as is true with all services reported using CPT codes.

The final step of introducing the new codes will be insurance companies establishing lists of diagnosis codes for which each of the three procedures will be paid. Medicare will likely publish a National Coverage Determination (NCD) for each code, replacing the NCD that had been in place for the 92135. In the meantime, physicians should continue to provide care based on each patient’s needs.

If in doubt regarding coverage, physicians should thoroughly explain the importance of the service and provide the patient with the opportunity to sign an Advance Beneficiary Notice (ABN) prior to providing the service. By signing the ABN, the patient may accept responsibility for payment for the service in the event the insurer rules the service to be “not reasonable and customary.”

You may also take some comfort in the fact that as this article is written no information is available regarding fees paid by commercial insurers for the new codes. Commercial insurers set their reimbursements independent from Medicare.

Summary of changes

To summarize the Medicare coding changes:

• Imaging codes 92135 and 0187T have been eliminated from CPT.
• Three new CPT codes have been created to replace them: 92132, 92133 and 92134.
• Either of the posterior codes, 92133 or 92134, may be billed on the same day as the anterior code, 92133.
• 92133 and 92134 may not be billed on the same day.
• Each of the new codes is bilateral.
• The relative values and, thus, the 2011 Medicare allowed charge for 92132 (unilateral/bilateral) is lower than the 2010 Medicare allowed charge for 92135 (unilateral).
• The 2011 allowed charges for 92133 and 92134 (both of which are unilateral/bilateral) are slightly higher than the 2010 allowed charge for 92135 (unilateral).

• Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., P.O. Box 608, Waupaca, WI 54981; Brownlowod@aol.com.