Question: How should I code for a nonconclusive HRT? One of our patients had one done, but due to her cataracts, the ophthalmologist was unable to get a clear reading. Should I report just the technical component of the code?
Florida Subscriber
Answer: Report 92133 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve) or 92134 (… retina) for the Heidelberg Retina Tomograph (HRT) study. Report the global code without appending modifier TC (Technical component).
In this case, your practice performed both the technical component and the professional component. Even if the provider could not make a final diagnosis based on the test, if he looked at the report and documents the findings, he gets credit for the professional component.
In the absence of a final diagnosis, report an ICD-9 code that describes the symptoms that prompted the test -- for example, 379.9x (Unspecified disorder of eye and adnexa), or 796.4 (Other abnormal clinical findings) if the patient has increased intraocular pressure, which could indicate glaucoma.