The use of scanning computerized ophthalmic diagnostic imaging has become much more prevalent in the evaluation and management of anterior segment and posterior segment disease. Proper documentation in the patient record, as well as proper coding, is essential in achieving reimbursement.
One Code for Any Instrument
Although numerous instruments (ocular coherence tomographer, Heidelberg Retina Tomograph, Zeiss GDx) can be used in posterior segment tomographic imaging, all are reported using the same CPT code: 92135. When scanning the anterior segment, use the CPT code 0187T. Carriers set the same level of reimbursement regardless of the instrumentation used to obtain the image.
These procedures are almost always listed as unilateral codes. The modifier -RT (right) and/or -LT (left) should be used on all claims to identify which eye was imaged.
Document Medical Necessity
Most, if not all, insurance carriers have published coding and billing policies on these procedures. Be sure to obtain copies of all published carrier policies prior to performing these procedures. And, thoroughly review the ICD9-CM diagnostic codes that support medical necessity. The primary diagnosis listed on the claim form must support the medical necessity of the testing. Remember, as with other ophthalmic testing codes, the reimbursement you receive includes your fee for the interpretation of the test.
Imaging is among the few eye care procedures that not only has a listing of ICD9-CM linked to the payment, but also has detailed parameters of the patients medical condition that must be met and documented prior to performing the imaging. So, there needs to be a complete ophthalmological examination (perhaps performed at an earlier encounter) describing the indications that support the medical necessity for the diagnostic imaging.
For example, before performing diagnostic imaging on a glaucoma suspect, most insurance carriers mandate that you document at least one of the following conditions: evidence of asymmetric cupping; applanation pressure greater than 22mm Hg; symmetrical or vertically elongated cup enlargement with a cup-to-disc ratio greater than 0.40; focal optic disk notch; either history or presence of an optic disc hemorrhage.
Clearly, use of ICD9-CM code 365.0 (borderline glaucoma [glaucoma suspect]) without support documentation of any of these conditions will not meet the standard to allow payment for the imaging.
Frequency of Imaging
Also, be aware that most payment policies limit how frequently the imaging may be performed. In the example of a glaucoma suspect, most carriers will allow a scan only once in a twelve-month period. If you are managing a glaucoma patient, the frequency may change to once every six months.
Any deviation from the carriers outline schedule may trigger a post-payment review of the medical record, where your documentation skills will be greatly scrutinized.
If you also perform fundus photography (92250), be aware of the impact of the Correct Coding Initiatives. Most insurance carriers do not allow payment for both fundus photography and diagnostic imaging on the same date of service (unless an allowable modifier is added to the procedure code). These are mutually exclusive procedures, so avoid scheduling them on the same date of service, if possible.
The use of scanning computer diagnostic imaging has greatly enhanced and advanced the level of care we provide to our patients. However, you must be aware of all the documentation and coding criteria that apply prior to submitting claims to assure that you achieve the proper level of reimbursement in a timely manner.
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