Ophthalmology and Optometry Coding Alert

Billing both of these codes together could land you in hot water.

Eye care practices frequently perform scanning computerized ophthalmic diagnostic imaging (SCODI) to examine the fundus, typically for conditions such as macular degeneration, glaucoma, and diabetic retinopathy. But billing for these services can be tricky, and recovery audit contractors (RACs) have picked up on the most frequent errors — which recently prompted one RAC to launch a review of these services.

Here’s the scoop: Part B RAC Cotiviti began listing “Ophthalmic Diagnostic CPT^® Codes: Excessive Units” among its approved issues as of June 19, 2019. The codes in question are:

• 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve)
• 92134 (… retina )

“CPT^® codes 92133 and/or 92134 will be considered in this edit, if billed together during the same patient encounter, on the same date of service,” Cotiviti says on its “Approved Issues” page. “Only one is allowed per day, therefore the lower allowed amount CPT^® Code will be recovered as an overpayment. Based on CPT^® Code descriptions, 92133 and/or 92134 cannot be reported at the same patient encounter.”

Indeed, CPT^® does have a notation listed in the manual under 92134 stating, “Do not report 92133 and 92134 at the same patient encounter.” However, many practices remain confused about reporting these services, as evidenced by the need for the RACs putting these procedures under review. To get a handle on how to properly bill these codes and stay out of the RACs’ crosshairs, check out these frequently-asked questions about these services.

FAQ 1: What’s the Difference Between the Codes?

The only factor differentiating the two codes is the location that the physician is examining. For a scan of the optic nerve, you’ll use 92133, and if the physician instead examines the retina, then 92134 is the better option.

FAQ 2: What Are the Coverage Guidelines?

According to the Local Coverage Determination (LCD) from Part B MAC First Coast Service Options, which was revised just last year, posterior segment SCODI is payable in the following instances:

1. For diagnosis and management of a patient who has mild, moderate, severe, or indeterminate stage glaucoma or who is suspected of having glaucoma.
2. Monitoring patients being treated with chloroquine (CQ) and/or hydroxychloroquine (HCQ) for the development of retinopathy.
3. The evaluation and treatment of patients with conditions affecting the optic nerve (e.g., optic neuropathy) or retinal disease (e.g., macular degeneration, diabetic retinopathy) and in the evaluation and treatment of certain macular abnormalities (e.g., macular edema, atrophy associated with degenerative retinal diseases).

“Documentation should support that the SCODI test result was used for establishing a diagnosis, establishing a baseline prior to treatment, or for monitoring purposes,” the MAC notes. In addition, screening using these tests is not typically considered medically necessary.

FAQ 3: How Much Can I Collect for These Codes?

The national average pay for 92133 is about $38, while you’ll collect approximately $42 for 92134. These payment amounts refer to the global code, so if you use a modifier such as 26 (Professional component) or TC (Technical component), you can expect a lower amount.