Ophthalmology and Optometry Coding Alert

Knowing that OCT is reported with the SCODI code won't cut it if you want to be reimbursed for OCT, you have to know the five rules that apply to claims submitted for 92135. Optical coherence tomography (OCT) is a noncontact, noninvasive imaging technology that produces cross-sectional images of the retina and evaluates the optic nerve fiber layer in glaucoma. These five coding rules that apply to reporting code 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) for OCT performed to diagnose glaucoma will help you keep your claims clean. Rule 1: When OCT is performed bilaterally, 92135 must be reported either with modifier -50 (Bilateral procedure), with the alpha-modifiers -LT and -RT, or with a "2" in the units column. Code 92135 is considered inherently unilateral, says Danielle Smith, CPC, coding specialist with Maine Eye Care Associates in Waterville. In other words, the fee allotted for 92135 only accounts for what is involved in performing the scanning done in one eye. "We bill OCT on two lines with -RT and -LT for all insurance carriers except Medicare," Smith says. Medicare requires that we use modifier -50 with two units, she adds. But you have to check your carriers' policies to determine their preferred method of reporting bilateral OCT. Think of it as "billed per eye, not per patient," says Michael J. Yaros, MD, a practicing ophthalmologist based in Runnemede, N.J. Most Medicare carriers prefer 92135-50, whereas private carriers reimburse more consistently with the use of the -RT and -LT modifiers, says Raequell Duran,president of Practice Solutions in Santa Barbara, Calif. Remember that when a service is considered "unilateral" in the Medicare program, the service is allowed at 100 percent of the fee schedule. If the service is performed and billed for both eyes, the claim should reflect an allowed amount of 200 percent. Rule 2: The physician must include a documented order for OCT in the patient's chart. "If the patient is required to come back for referral or scheduling reasons, the reason the test was ordered" should be documented in the previous dictations, Smith says. "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. "If both eyes are done, then both have to have the documentation to go with them," she warns. Rule 3: 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 [...]