Ophthalmology and Optometry Coding Alert

Denied Again for OCT? Not if You Abide by These 5 Rules

Published on Sun Jun 01, 2003

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 medical necessity.

"There should be medical necessity for each eye, since each is a separate test, much like fluorescein angiography," Yaros says. "You cannot do the other just for comparison only."

Rule 4: 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, Yaros says.

Rule 5: 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, e.g., visual field examinations and fundus photography. You also need to be aware of carriers' specific frequency guidelines and coverage requirements.

For example, CIGNA Medicare in North Carolina gives the following guidelines for scanning laser glaucoma tests:

Once per year for preglaucoma patients or those with mild damage. One or two tests per year may be used for patients with moderate damage; however, if both scanning laser glaucoma tests and visual fields are used, only one of each test is necessary.

For patients with advanced damage, laser scanning is not preferred; it is seen as not beneficial or necessary, and visual field testing is preferred instead.

Here are some additional billing guidelines to obtaining reimbursement.

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 for codes you can't bill with 92135; these frequently include 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 ... contact B-scan [with or without simultaneous A-scan]).

OCT is usually a covered service for Medicare because doctors mostly perform this service for patients diagnosed with glaucoma, Smith says. If they perform OCT for a diagnosis that 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, she says.

"For this, or any test, an ABN is needed if you have reason to believe Medicare might not cover the test," Yaros says. "This could be because they have stated so, or, for example, because you are using it more frequently than usual."

You should always check your Medicare carriers' and private carriers' local policies before performing OCT to make sure it is being performed for a covered diagnosis you don't want to be stuck footing the bill because you didn't have a patient sign an advance beneficiary notice.