Coding

Should I code for OCT or fundus photography?

Recent update provides clarity to ensure proper payment.

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

Along with local and national payer guidelines, we think of CPT (Current Procedural Terminology) as an official source of coding information. CPT Assistant, published by the American Medical Association, also contains areas in each issue for most medical specialties — its cover tagline reads the “official source for CPT coding guidance.”

This monthly magazine recently provided much-needed advice for eyecare providers on how to properly use CPT codes 92250, 92133, and 92134.

Autofluorescence (AF) imaging

Some cameras have filters that allow for AF fundus imaging of the retina or optic nerve. Some publications have advised that AF services should be billed using CPT code 92499 (unlisted ophthalmological service), while others gave different advice. The December 2014 CPT Assistant provided clarity.

“Question: When an ophthalmologic photographer takes AF images without the need for intravenous fluorescein or indocyanine green, how would AF imaging be reported?”

“Answer: Code 92250, Fundus photography (FP) with interpretation and report, would be reported either as part of a series of images or as a stand-alone service. An analogous service … obtaining red-free images at the time of color photography, is not reported separately.”

Additionally, this article makes it clear that reporting 92250 on a second line for AF or red-free imaging on a claim for the same date of service as other 92250 services is improper since it “is not reported separately.”

Via scanning laser ophthalmoscope (SLO) technology

Until 2011, OCT (scanning computerized ophthalmic diagnostic imaging, or SCODI) was reported with a single CPT code, 92135. Since then, we use 92133 and 92134 to report posterior segment SCODI imaging of the optic nerve and retina, respectively. These codes included the phrase “unilateral or bilateral,” so they are billed per patient encounter and not “per eye” as was the case with the 92135 code. This significantly reduced the reimbursement, and offices were motivated to bill 92135 over 92250 because of higher reimbursement when both were done on the same day.

Some offices have instruments that create both FP and SCODI imaging with the push of a button — in some cases, via a scanning laser ophthalmoscope (SLO). In this situation, offices did not know what code to choose.

Controversy existed since 2011 because of the April 1999 decision that referenced the now-deleted 92135 code. It seemed as though code selection was left up to the user when an SLO was used. The November 2014 CPT Assistant provided an update:

“Question: Our office performs FP examinations using a scanning laser, which produces a fundus photograph. Is it appropriate to report CPT code 92135 [now codes 92133 and 92134] for this method of examination of the fundus?”

“Answer: If the scanner produces an image of the retina or optic nerve along with other data and imaging for quantitative analysis, it would be appropriate to report a single service from the appropriate scanning computerized ophthalmic diagnostic imaging code range (92133-92134). If only an image is obtained, then code 92250 would be reported.

“It is important to note that if the only necessary service provided is generating a fundus photograph without the need to quantify the nerve fiber layer and to analyze the data via a computer, then reporting code 92250 is appropriate, even if the photograph was taken with a scanning laser.”

The bundles and edits in place for SCODI of the posterior segment and FP remain for the same date of service; you can’t bill 92133/4 and 92250 unless the testing is medically necessary and performed on different dates.

Necessary clarity

CPT Assistant made it clear that the indication for “turning on” the machine (fundus imaging alone, or discrete data analysis with or without fundus imaging) determines the code when imaging is done via SLO methodology. As a result, how your office’s medical charts reflect the order and the medical necessity in the setting of SLO imaging is the key to supporting the code selected.

For example, if your SLO imaged the fundus and produced an OCT image and you chose code 92250 but the order in the chart showed the provider needed the data analysis afforded with SCODI, you chose improperly; an overpayment might exist since 92133/4 was proper and pays less than 92250. However, if you chose 92133/4 solely because of the bundles but the provider needed only a fundus image and no discrete data analysis, you asked the payer for less than you were entitled — code 92250 was proper and generally pays more.

Coding involves awareness of multiple sources of instruction, including CPT, local and national payer guidelines, and in certain cases, CPT Assistant. Without the recent clarity, controversy surrounded proper coding for both AF and FP/OCT in certain situations. Due to inaccurate advice, some offices may have chosen codes and/or modifiers that significantly overpaid or underpaid when done in volume. OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.