Riva Lee Asbell
With the advent of a new and revised coding system for the diagnostic
tests collectively known as Scanning Computerized Ophthalmic Diagnostic
Imaging, or SCODI, a barrage of questions has emerged amidst confusion. This
review addresses these issues regarding optical coherence tomography and
pertains to Medicare only. Other insurers are making independent decisions and
may be slow in their implementation. Each insurer should be contacted directly.
History and 2011 code changes
The Current Procedural Terminology code for SCODI was originally
developed as a glaucoma diagnostic test. Retina diagnosis usage and codes were
added to the coverage, and finally, in 2011, anterior segment diagnoses were
given a Category I CPT code, raised from a Category III code (0187T).
The codes involved, effective Jan. 1, 2011, from the 2011 CPT, are:
92132 Scanning computerized ophthalmic diagnostic imaging, anterior
segment, with interpretation and report, unilateral or bilateral
92133 Scanning computerized ophthalmic diagnostic imaging, posterior
segment, with interpretation and report, unilateral or bilateral; optic nerve
Note that in CPT when a code such as 92134 is indented, the code
description from the preceding non-indented code up to the semicolon is
included in the code description. Thus, 92134 technically reads:
92134 Scanning computerized ophthalmic diagnostic imaging, posterior
segment, with interpretation and report, unilateral or bilateral; retina
The CPT codes formerly used (92135 and 0187T) can only be used for
services provided up to Dec. 31, 2010, for Medicare. Other insurers are in the
process of making determinations on reimbursement for this.
The impetus that drove the Centers for Medicare and Medicaid Services to
make these changes involved utilization and payment issues.
The national average payment for the procedures is as follows:
92132 = $36.35
92133 = $44.51
92134 = $44.51
The fee is paid only once whether one or both eyes are tested. The
significant change from the old CPT code 92135 to the new codes (92132, 92133
and 92134) is that SCODI is now paid once for both sides whereas it was
formerly paid for each side. This effectively halved the payment for the test
when it is performed bilaterally.
Technically, no modifiers are required for this test. It is possible
that Medicare contractors may require them in the future. Be guided by your
Local Coverage Determination. You do not need to use modifier 52 (reduced
services) when performing the test on one eye. Ordinarily if a test is deemed
bilateral on the Medicare Physician Fee Schedule Database, such as fundus
photos, and is only performed on one side of paired organ systems, then
modifier 52 should be applied. However, in this case the descriptor of
unilateral or bilateral negates that.
CPT instructions and NCCI bundles
CPT instructions after the codes in the 2011 book state:
(Do not report 92133 and 92134 at the same patient
(92135 has been deleted)
(for scanning computerized ophthalmic diagnostic imaging of the
optic nerve and retina, see 92133, 92134)
In version 17.0 of the National Correct Coding Initiative (NCCI), the
obvious occurred, and 92133 and 92134 were bundled. However, the modifier
indicator is 0, meaning that you cannot use modifier 59 to break
the bundle under any circumstances.
Thus, there are the following code edit pairs:
The first and second code edit pairs have a modifier indicator of 1,
which means under appropriate circumstances the edit can be broken by using
modifier 59. I would advise against doing that with the exception of the test
being performed for a condition in one eye (eg, wet macular degeneration) and
the other test being performed for a condition in the fellow eye (eg, anterior
Remember, the code pair edits apply only to services performed on the
same date of service.
Fundus photo NCCI bundles
The origin of the fundus photo bundles with SCODI dates back to when the
code was first developed. Many practices were billing for both tests but not
actually performing separate fundus photos; they were merely part of the SCODI
test (a recreation of the optic nerve). Do not unbundle them unless your
Medicare contractor specifies that it is allowed. A draft policy that does is
currently posted for First Coast Service Options in Florida. It remains to be
seen whether it is put into effect or not.
Fundus photos (CPT code 92250) and OCT for retina (CPT code 92134) are
bundled mutually exclusively in the NCCI. The national average payment for
fundus photos is $73.38 and for OCT retina is $44.51.
If both are coded together, the lowest-paying one is paid. If both
fundus photos and OCT are medically necessary, technically you can bill only
for the fundus photos; however, I caution you to be absolutely certain
additional information is gained from each test. For those patients with
choroidal neovascularization, for example, who have OCT scans done in
conjunction with the determination of whether an injection should be performed
or for monitoring the test, then the test that should be billed is the OCT.
In Part 2, we will look at Medicare compliance issues and following your
Medicare Administrative Contractors Local Coverage Determinations.
- CPT codes copyright American Medical Association 2011.
- Riva Lee Asbell is president of Riva Lee Asbell Associates, an
ophthalmic reimbursement consulting firm, and a clinical assistant professor of
surgery (ophthalmology) at the University of Medicine and Dentistry of New
Jersey/Robert Wood Johnson Medical School at Camden. She can be reached at
The discontinuation of CPT 92135 and the inauguration of three
replacement codes (92132, 92133, 92134) is a significant change for
ophthalmologists and optometrists. It was not unexpected. The volume of testing
with SCODI has grown rapidly during the past dozen years and will likely
continue to grow after the anticipated precipitous drop in 2011 since per eye
billing stopped. Postpayment audits for prior claims will likely escalate due
to aggressive billing, particularly the misuse of modifier -59 with fundus
photography. Payments will decrease due to the change to unilateral or
bilateral in the description. Finally, new policies will be written for
each CPT code to replace the old policy for 92135 and, thereby, clarify
coverage and payment rules for different indications.
Kevin J. Corcoran, COE, CPC, FNAO
President, Corcoran Consulting Group
San Bernardino, Calif.
Disclosure: No products or companies are mentioned that would require financial