Wiki OCT'S on patients with diabetes

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jro51081@yahoo.com

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Local Chapter Officer
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What is everyone doing when billing macula scan (92134) when a patient has diabetes, and other dx's seem to be kicking back also. Are you just not charging for this service, or getting an ABN? We are doing a lot of OCT'S right now and not getting to bill for them??? Any input would be great! Thank you!

Jennifer Rogers
Berg Eye Group
jrogers@bergeye.com
 
what codes are you currently using? what is the patient diagnosis for the procedure? If this is a screening in a patient with diabetes with no current complications the you need a screening Z code first listed and the diabetes as E10.9 or E11.9. The payer may not pay due to coverage so what does the denial indicate?
 
Oct's

Hey Debra, thank you for responding! We don't even file our OCT'S because we know Medicare will not pay for just E10.9 or E11.9. I will try it with a Z code and see if that works. We do one on most all diabetic patients to see if there is any diabetic retinopathy and if they do not we can only use E10.9/E11.9, but we have to do it to find out.
 
Not going to pay for screening scans

Jennifer, I'm not quite sure why you need to do the OCT to see if there's diabetic retinopathy. When the doctor examines the patient through the dilated pupil, they should be able to detect any signs of DR. Realistically, you're going to see retinal hemorrhages in the vast majority of cases before you will see any macular edema.

Therefore, if no retinal hemorrhages are noted, there isn't really a need to do a macular OCT unless macular changes are detected without any hemorrhages, in the rare cases where that occurs.

If you find the DR, then you can code the E10 or E11 code with the appropriate description of the level of DR with or without macular edema and bill the OCT and it should be paid. Otherwise, without any signs of DR or edema, your OCT scan are realistically just screening scans and won't be paid by any insurer. If you want the patient to pay for these screening scans, then you need to use either an ABN, if you're still going to file for the OCT without the DR, or have them do a NEMB form and just have them pay you up front.

Tom Cheezum, O.D., CPC, COPC
 
Oct's

Hey Tom, thank you for responding. I have 2 doctors that want an OCT on all diabetic patients, and 2 that only want one if they are complaining of decrease in vision. I guess we are just not going to be able to bill for those, which is what we have been doing. I was hoping someone could give me a reason so we could get paid for these. Oh well, thanks!

Jennifer Rogers
 
Jennifer, just a quick question for you. Are these OCT scans being done as part of the pt work up prior to them being seen by the doctor? If so, and there isn't a prior order for the scan detailing why it will be done, then technically, even if the scan does show DR changes, you can't bill that to insurance. From a timing standpoint, the order needs to be in the chart prior to the test actually being doing. I've heard a couple of auditors say that they are looking at the meta data in the EMR software and in the scanner software to compare times. If the sequence isn't correct, then the scans fees are disallowed, even if pathology is present.

Tom Cheezum, O.D., CPC, COPC
 
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