In today’s world of outcome-based care and intense scrutiny of medical necessity for clinical testing, questions of reimbursements and subsequent economics have become integral when considering purchasing or leasing a new piece of diagnostic equipment. They may be just as important to consider as whether or not the new technology will improve patient care.
It’s better to know in advance how to code specific procedures, and what you can and cannot bill for when buying new equipment; guessing after the fact can get you into trouble.
Fueling the Flames
As an example, let’s look at the somewhat recent release of optical coherence tomography angiography (OCT-A). When this technology was first introduced in the literature in 2008, it was recognized as a ground-breaking diagnostic device for the earlier detection of disease and more effective management of disease states.1 The first OCT-A instrument became commercially available in the United States in September 2015 and has the potential to replace intravenous dye-based angiography for most macular diseases.
As with any new technology, most clinicians have a strong desire to incorporate the latest and greatest into their practice. This is where the “reimbursement noise” starts to hit the chat rooms and blogs—clinicians begin informally discussing ways to bill for the new diagnostic tests. Unfortunately, most of the rhetoric in these forums is not factual; it’s simply the result of creative billing by many to enhance reimbursements. This, of course, is driven by the higher cost of the new technology and the desire to reach the break-even and profitability curve more quickly.
On a popular OD website, one clinician recommended that ODs bill OCT-A as follows:
92134 – (regular OCT of the retina)
92499 – Enhanced angiography portion of OCT
Many who follow this website believed this was a legitimate way to bill for OCT-A and were quite happy with the increased reimbursement they received, even if the additional portion was being paid by the patient. Positive stories and feedback on this post fed the flames, and the behavior soon became common.
Extinguish the Hype
This coding path had a major flaw. The American Medical Association publication of the CPT clearly defines the coding of OCT-A to be exactly the same as coding for OCT: 92134. This code alone is the proper way to code the procedure—no enhancements or embellishments, and no increased reimbursement.
The February 2011 CPT Assistant discusses CPT 92134: “For the posterior segment, two distinct areas are imaged using the new technology, the optic nerve and the retina. The evaluation of the images differs. Consequently, codes 92133 and 92134 have been added to report scanning computerized ophthalmic diagnostic imaging of the optic nerve and retina, respectively [...] Code 92134 describes scanning computerized ophthalmic diagnostic imaging of the retina.”2
Furthermore, local coverage determinations by CMS regional carriers also provide guidance and acknowledge that using CPT code 92134 is appropriate for OCT-A. Using any additional codes is duplicative, inappropriate and unwarranted.
This reimbursement issue clearly affects the decision-making process when acquiring new technology in a practice. While you may not like it, this is the prevailing rule as of today, and upcoding this procedure to a carrier or, worse yet, charging it to the patient is problematic for a multitude of reasons that can all lead to greater audit exposure and monetary fines. If you are coding and billing a procedure with the knowledge that you are doing so incorrectly, that is tantamount to doing so with intent and is thus considered fraud, not waste and abuse; fraud convictions are generally criminal, not civil.
Knowing the rules is paramount, not only when crunching the numbers to justify purchasing a new and exciting diagnostic tool but when considering its day-to-day use as well.
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1. Fingler J, Readhead C, Schwartz DM, Fraser SE. Phase-contrast OCT imaging of transverse flows in the mouse retina and choroid. Invest Ophthalmol Vis Sci. 2008;49(11):5055-9.