Ophthalmology and Optometry Coding Alert

When you examine a glaucoma patient, some carriers limit additional diagnostic procedures. They may object if you bill a comprehensive visit (92004 or 92014), visual fields (92081-92083), the scanning laser 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) and 92250 (Fundus photography with interpretation and report) on the same day. Most controversial at this time is the scanning laser, a relatively new addition to glaucoma diagnostic procedures.

For example, HealthNow (Empire New York), Palmetto GBA (South Carolina), and Trailblazer (Maryland and metropolitan Washington, D.C.) will not pay for 92135 with 92250, 92225 (Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial), 92226 ( subsequent) or 76512 (Ophthalmic ultrasound, echography, diagnostic; contact B-scan [with or without simultaneous A-scan]).

The local medical review policy (LMRP) for First Coast (Florida) doesn't refer to 92250, 92225, 92226 and 76512 and does not indicate that ophthalmologists cannot perform two procedures together (e.g., fundus photography and the scanning laser). However, the LMRP includes a general comment about using 92135 for confirmation only: "In addition, scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary when performed to provide additional confirmatory information regarding a diagnosis which has already been determined."

The HealthNow and Palmetto GBA LMRPs also recommend visual field testing instead of the scanning laser (referred to as SLGT in the HealthNow LMRP) under certain conditions. If damage is advanced, the HealthNow LMRP states, use visual field testing (92081-92083) instead of SLGT (92135). "It would rarely be necessary to perform more than four visual fields in a year in 'advanced damage,' and SLGT would rarely be necessary or beneficial."

For patients with mild damage, the HealthNow, First Coast and Palmetto GBA policies allow one test per year. Patients with "moderate damage" may have two tests per year, but if visual fields and the scanning laser are used, each may be used only once.

Trailblazer for Maryland mainly agrees with the other three policies but also prohibits 92135 "on a yearly or routine basis as a screening examination for glaucoma." However, 92135 is allowed under the Trailblazer LMRP for patients who have glaucoma if the appropriate diagnosis (almost any glaucoma diagnosis as well as some retinal and iris diagnoses) is reported.

The HealthNow and Palmetto GBA LMRPs stress that 92135 will be denied if used for the confirmation of a known diagnosis. "For example, early in glaucoma the technique of SLGT is more sensitive in detecting glaucomatous damage," the LMRP for HealthNow states. "Late in the course of glaucoma when the nerve fiber layer has been extensively damaged, visual fields are more likely to detect small changes than are changes in SLGT. Therefore, it is not necessary to diagnose and follow glaucoma using both tests at yearly or sometimes shorter intervals." First Coast calls 92135 and visual field tests "duplicative."

Trailblazer for Maryland, which refers to 92135 as LCT (laser coherence tomography) instead of SGLT, doesn't have the same clear frequency limitations. But the LMRP states that it is not medically necessary to perform 92135 with 92250, 92225, 92226 and/or 76512 to diagnose or follow glaucoma.