Medicare Reimbursement for SCODI of the Posterior Segment

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR SCODI OF THE POSTERIOR SEGMENT

For best results, please view in Mozilla Firefox.

Q: Does Medicare cover SCODI of the posterior segment with Topcon’s 3D OCT-1 Maestro2?

A: Yes. Scanning computerized ophthalmic diagnostic imaging of the posterior segment (SCODI-P) is covered by Medicare subject to the limitations in its payment policies; other third party payers generally agree. Medicare covers SCODI-P if the patient presents with a complaint that leads you to perform this test or as an adjunct to management and treatment of a known disease. If the images are taken as baseline documentation of a healthy eye or as preventative medicine to screen for potential disease, then it is not covered (even if disease is identified). Also, this test is not covered if performed for an indication that is not cited in the local coverage policy. Check your local policies; they vary.

Q: What CPT codes describe SCODI-P?

A: There are two CPT codes to describe SCODI-P.

92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

The 3D OCT-1 is a spectral domain OCT which utilizes different technology than some other OCT instruments to reduce the effect of eye movement; however, CPT coding is the same as other SCODI-P instruments.

If both tests are performed concurrently, use the primary indication for testing as the deciding factor and choose just one code – not both.

Q: What are the indications for SCODI-P?

A: The list of diagnoses is lengthy and includes glaucoma, macular degeneration, and other posterior segment diseases. Specific lists of covered diagnoses vary by payer.

Q: What documentation is required in the medical record to support a claim for SCODI-P?

A: In addition to a printout or proof that images exist, the chart should contain:

an order for the test with medical rationale
the date of the test
the reliability of the test
the test findings (e.g., thinning, thickening, separation of layers)
comparison with prior SCODI-P tests
a diagnosis (if possible)
the impact on treatment and prognosis
the signature of the physician

QUESTION: Are there payment restrictions or bundles that limit what other codes may be billed the same day?

ANSWER: Yes. CPT instructs that 92133 and 92134 may not be reported at the same patient encounter. Medicare’s National Correct Coding Initiative (NCCI) treats fundus photography (92250) as mutually exclusive with SCODI-P. The E/M service 99211 is bundled with this test.

Several Medicare Administrative Contractors (MACs) publish policies that impose other restrictions when performing SCODI-P with B-scans (76512) and extended ophthalmoscopy (92201, 92202). Check your payer policies; they vary.

QUESTION: How much does Medicare allow for this test?

ANSWER: Both 92133 and 92134 are bilateral services and reimbursed the same whether one or both eyes are tested. The 2022 national Medicare Physician Fee Schedule allowances are:

Values are adjusted in each area by local wage indices. Other payers set their own rates, which
may differ significantly from Medicare.

SCODI-P is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.

Q: How often may SCODI-P be repeated?

A:92133 is generally allowed 1-2 times per year for glaucomatous patients, usually for early or moderate disease. 92134 is allowed more often, typically up to 4 times per year. It is usually allowed once per month in patients with retinal conditions undergoing active intravitreal drug treatment.¹ Clear documentation of the reason for testing is always required. Too-frequent testing can garner unwanted attention.

CMS utilization rates for 2018 claims show that 92133 was associated with 10% of all ophthalmology exams. That is, for every 100 exams for Medicare beneficiaries, Medicare paid for this service 9 times. For 92134, the 2018 utilization was 31%. For optometry, the utilization was about 8% for both codes.

Q: Is the physician’s presence required while SCODI-P is being performed?

A: Under Medicare program standards, SCODI-P only needs general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the test. Other payers generally agree.

Q: If coverage of is unlikely or uncertain, how should we proceed?

A: Explain that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN form.
For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

¹ CGS Administrators, LLC. LCD L34061. Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI). Rev eff. 07/29/21. Link here.

Provided Courtesy of Topcon Medical Systems (800) 223-1130

Last updated March 8, 2022

The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, the reader is reminded that this information, including references and hyperlinks, changes over
time, and may be incorrect at any time following publication.

© 2022 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.

Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com