Ophthalmology and Optometry Coding Alert

Question: We have a patient with ocular hypertension and we did a GDX scan for her. (Editors note: A GDX is the same thing as an optic disk scanning laser.) We billed the GDX as 92135 (scanning computerized ophthalmic diagnostic imaging [e.g. scanning laser] with interpretation and report, unilateral) per eye with a 365.04 (borderline glaucoma; ocular hypertension) diagnosis code. The patients insurance denied the claim because the diagnosis does not support the service. Before we appeal, is there a better diagnosis that an insurance company may accept?

John Frederick
Golden, Colo.

Answer: Unless you have documented another condition, such as 377.14 (optic atrophy; glaucomatous atrophy [cupping] of optic disc), the only diagnosis you can report is 365.04. There are books that are sold called code-links that reference what combination of CPT code and diagnosis code typically will be paid by insurance companies. But if you have not documented the condition in the medical record, you would be submitting a false claim to the insurance company. The best thing to do is to appeal the claim to the insurance company explaining the medical necessity for the service that was rendered.

When dealing with Medicare, if there is a diagnosis code that you feel should be listed as a covered diagnosis, then you can contact your state ophthalmological society and ask them to have the TPR (third party representative) contact the carrier to have the covered diagnosis list expanded.