Ophthalmology and Optometry Coding Alert

Knowing the right codes for OCT can save your office $40 per service

If you're getting denials for optical coherence tomography (OCT) retinal imaging procedures, you could be doing one of five things wrong, experts say.

Report 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) for OCT performed to diagnose correctly by following these rules.

When OCT is performed bilaterally, you must report 92135 either with modifier -50 (Bilateral procedure), with the alpha-modifiers -LT and -RT, or with a "2" in the units column, says Cindy Holt, CPC, insurance billing coordinator for the Eye Center of Central Georgia in Macon. Code 92135 is considered inherently unilateral -- the fee allotted for 92135 only accounts for what is involved in performing the scanning done in one eye.

Most Medicare carriers prefer 92135-50, whereas private carriers reimburse more consistently with the use of the -RT and -LT modifiers.

The ophthalmologist must include a documented order for OCT in the patient's chart, says Holt. If the patient needs to come back for referral or scheduling reasons, the reason the test was ordered should be documented in the previous dictations. If OCT is done the same day, it should also be documented. Be sure the ophthalmologist has documented orders for both eyes before billing the service bilaterally.

The physician must document the reason for the diagnostic OCT in the patient's record, and the reason has to demonstrate medical necessity. For example, if a patient presents with increased intraocular pressure, OCT can help determine whether the patient is in the early stages of glaucoma, a circumstance that constitutes medical necessity. There should be medical necessity for each eye, since each is a separate test.

To report code 92135, the physician must include a written interpretation and report that includes any findings and observations from the imaging report. The report should explain what findings the physician is able to abstract from the test. The interpretation of the test results should also include any issues of the quality of the test, reliability of the findings, and any implications for treatment or further care.

You must check your carrier's local medical review policies for any carrier-specific requirements when reporting code 92135. Many carriers have their own rules for reporting 92135 when performed at the same time as other diagnostic tests, for example, visual field examinations and fundus photography.

Medicare considers 92135 and 92250 (Fundus photography with interpretation and report) to be mutually exclusive; you should not report those two codes together. You also need to be aware of carriers'specific frequency guidelines and coverage requirements.

Tip: Don't bundle the procedure when unnecessary. When administering this test with an office visit done on the same day, you can charge for both the visit and the scan separately.

And check your carrier's guidelines and LMRPs for codes you can't bill with 92135. For example, Palmetto GBA, the Medicare carrier for South Carolina, will not cover 92250 (Fundus photography with interpretation and report), 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial), 92226 (... subsequent), and 76512 (Ophthalmic ultrasound, echography, diagnostic; contact B-scan [with or without simultaneous A-scan]) with 92135, reports Tammy Harmon, CPC, billing manger for Atlantic Ophthalmology in Beaufort, S.C.

OCT is usually a covered service for Medicare because doctors mostly perform this service for patients diagnosed with glaucoma. If the diagnosis is not listed as covered for Medicare, the ophthalmologist writes a letter to substantiate medical necessity to the Medicare carrier and will typically be reimbursed.