The Code.

• CPT Code 92135 has been deleted effective January 1, 2011.
• The new code for OCT in 2011 for retina practices is:
  92134 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral; retina.
  
  

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Characteristics.

• The significant change is that 92134 is paid once for both sides whereas formerly the test was paid for each side, and this essentially halves the reimbursement.
• Modifiers are not necessary unless mandated by your Medicare contractor/carrier. Do not use modifier 50 or bill separately with RT and LT modifiers.
• National Correct Coding Initiative (NCCI) bundles are in place with the other SCODI codes as well as fundus photographs.

Intravitreal Injections.

• Since a patient is evaluated for an intravitreal injection based on the OCT findings, then that is the test for which there is medical necessity; the fundus photos have only a secondary role, if any, in the medical decision making.
• If an office visit is going to be billed the same day as the intravitreal injection by appending modifier 25, then OCT becomes the diagnostic test for which there is medical necessity.

There must be medical necessity for performing the fundus photos; do not simply order them so you can bill them instead of the OCT.

Do's.

• The requirement of "interpretation and report" applies to OCT. Review the article on my website (www.RivaLeeAsbell.com) entitled "The Three C's: Interpretation and Report Requirements for Diagnostic Testing."
• Look up the LCDs (Local Coverage Determination) and associated billing articles from your Medicare contractor/carrier for the new codes. They give you covered diagnoses and other important information.
• Review and adhere to the signature requirements by Medicare, particularly in respect to CERT audits. Be sure the order for the test is signed as well as the Interpretation and Report.
  

Don'ts.

• 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.
• Do not break the "bundles" in order to capture the significantly higher reimbursement for the fundus photos. You risk a serious audit. First Coast Service Options has issued a LCD that outlines when the bundles can be broken, but this is only for Florida.
• If both tests are medically necessary, technically you could 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/treating the condition, then the test that should be billed is the OCT.

For more detailed information see my Coding Q & A columns in the January-February, March and April issues of Retinal Physician.