Optometry Coding & Billing Alert

Published on Sun Nov 21, 2010 PDF

Question: What diagnosis code should we use for OCT when the patient is currently on Plaquenil but not yet showing signs of macular degeneration, and there is no other diagnosis available that meets the CMS LCD requirements?

Answer: There is probably no way you can get reimbursed for optical coherence tomography (OCT) to check whether a drug a patient is taking is affecting his vision. For a Plaquenil check, the appropriate ICD-9 code would be a V code such as V58.69 (Long-term [current] use of other medications), with the patient's systemic condition -- the reason he's taking the drug, such as (714.x, Rheumatoid arthritis and other inflammatory polyarthropathies) -- as a secondary diagnosis. But those diagnosis codes are not on most carriers' lists of approved ICD-9 codes for 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser], with interpretation and report, unilateral).

Why not? Payers are apparently not convinced that OCT is an effective way to detect Plaquenil retinopathy (PR). However, if ophthalmologists can prove that the OCT can see PR earlier than a visual field test and dilated macular exam, then the diagnosis might be approved for OCT -- much like the glaucoma diagnoses (365.x) have already been.