Ophthalmology and Optometry Coding Alert

• 92134 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina)
• 92235 (Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral)
• 92250 (Fundus photography with interpretation and report)

For the optical coherence tomography, look in the Index under Ophthalmology, Diagnostic => Computerized Scanning => Posterior, which directs you to codes for scanning of the optic nerve (92133) and retina (92134).

Fluorescein => Angiography, Ocular directs you to three codes, including 92235. You can rule the other two out because indocyanine-green angiography was not done and because the imaging was of the posterior segment, not the anterior segment. In the index, look for Fundus under Photography; there, you’ll find 92250.

“Lastly, verify the coding edits to confirm which codes can or cannot be billed together,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. “The NCCI edits preclude reporting CPT^® 92134 and 92250 for the same patient on the same date of service,” she notes.

Navigate the Nuances of Diagnosis Coding

Physical exam and testing show blood vessel damage due to severe nonproliferative diabetic retinopathy (NPDR) with diabetic macular edema (DME) in both eyes.

Question: What ICD-10-CM codes are reported?

Answer: ICD-10-CM includes a number of codes that describe both the underlying condition (diabetes) and the ophthalmic manifestation (e.g., retinopathy, macular edema). Once you locate diabetic retinopathy in the ICD-10-CM code book, you’ll be able to narrow it down based on the level of retinopathy (mild, moderate, severe) and which eye is affected (left, right, bilateral).

Landing on the correct code requires that you know whether the patient has macular edema; in this case, that condition is present. The ICD-10-CM guidelines direct you to sequence diabetes codes “based on the reason for a particular encounter;” thus, your primary diagnosis code is E11.3413 (Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral).

However, you won’t stop there. You’ll see that the notes under E11.3413 in your ICD-10-CM code book indicate that you should use an additional code to identify control, as follows:

• Z79.4 (Long term (current) use of insulin)
• Z79.84 (Long term (current) use of oral hypoglycemic drugs …)

However, the patient is taking an injectable non-insulin antidiabetic drug, which is not one of those codes. But according to ICD-10-CM guideline I.C.4.a.3, in such cases, you should still assign Z79.85 (Long-term (current) use of injectable non-insulin antidiabetic drugs) to your claim following E11.3413, as the guideline states “additional code(s) should be assigned from category Z79 to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or injectable non-insulin antidiabetic.”

Take a Stab at Reporting VFE and IVA

Discussion with patient about options: OU 1. Observe 2. IVA (Eylea) Q8weeks 3. PRP Explained and informed R&B of options (without treatment DR progressing and vision declining). Agree to proceed with IVA OU within 1-2 weeks, VF24-2 prior to.

Question: The patient underwent extended visual field examination (VFE) on both eyes and then, four days later bilateral intravitreal aflibercept (IVA) injections. What codes are reported for the VFE and IVA?

Answer: VFE codes 92081, 92082, and 92083 are for limited, intermediate, and extended examinations, respectively, and Medicare considers them bilateral procedures. Since an extended VFE was done, use 92083 (Visual field examination, unilateral or bilateral, with interpretation and report; extended examination …). The documentation must include the physician’s order and demonstrate that a visual field test is necessary for diagnosis and future treatment and prognosis.

Your eye care specialist is likely to perform visual field testing frequently, as these services “detect defects in the field of vision, and test the function of the retina, optic nerve, and optic pathways,” according to Part B payer NGS’ Gail O’Leary. Keep in mind that gross visual field testing is considered part of a general ophthalmological service and shouldn’t be reported separately from those services, she said.

For treatment via intravitreal injection, use two codes on the claim: CPT^® code to describe the injection and HCPCS Level II code for the medication injected.

Report 67028 (Intravitreal injection of a pharmacologic agent …) for the IVA injection and append the appropriate modifier to identify the eye(s) involved: RT (Right side), LT (Left side), or 50 (Bilateral procedure). In this case, the retina specialist injected both eyes, so you’ll report 67028-50 on the claim.

“The ‘separate procedure’ rules and the global procedure rules preclude providers from billing for code 67028 in conjunction with or in the global period following related surgical services,” Johnson notes.

Submit J0178 (Injection, aflibercept, 1 mg) for the supply of the medication injected intravitreally. “Match the HCPCS definition of 1 unit of the medication with the dose administered and report the correct number of units on the claim,” Johnson says. “In this example, Eylea (aflibercept) was administered in each eye. The dosing information in the package insert notes a standard dose is 2mg/0.05ml. Report 2 units on the claim for reimbursement,” she adds.

“Retina services have received a fair amount of audit attention recently, in particular, intravitreal injections. Be sure your documentation is complete and includes the indication, consent, and a procedure note that includes pertinent information about the medication, including medication discarded, if any,” Johnson recommends.

Resources: >https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52451&ver=48&bc=0

www.regeneron.com/downloads/eylea_fpi.pdf