Ophthalmology and Optometry Coding Alert

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 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 doctor 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 be an indication of glaucoma.