Ophthalmology and Optometry Coding Alert

Question: How should I code for a nonconclusive Heidelberg Retina Tomograph (HRT)? One of our patients had one done, but due to her cataracts, the optometrist was unable to get a clear reading. Should I report just the technical component of the code?

Florida Subscriber

Answer: Report 92135 (Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) 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, 796.4 (Other abnormal clinical findings) if the patient has increased intraocular pressure, which could indicate glaucoma.