Medicare Reimbursement for SCODI of the Anterior Segment (Visionix)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR SCODI OF THE ANTERIOR SEGMENT
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Q What are the indications for SCODI of the anterior segment?
A There are many indications for scanning computerized ophthalmic diagnostic imaging of the anterior segment (SCODI-A) including: assessment of both corneal flap thickness and residual stromal thickness following LASIK, evaluation of anterior segment ocular structures, and measurement of anterior chamber angles.
Q What documentation is required in the medical record to support claims for SCODI-A?
A In addition to proof that digital 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., dislocated IOL)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the signature of the physician
Q What CPT code should we use to report SCODI-A on a claim for reimbursement?
A Use CPT 92132, Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral.
Q Does Medicare cover SCODI of the anterior segment?
A Yes, some MACs cover SCODI-A for evaluation of narrow angles, and disorders of the cornea, iris, and ciliary body. Many other third party payers have similar policies. Check local coverage policies for more information.
Q What is the reimbursement for 92132?
A CPT describes 92132 as “unilateral or bilateral” so this is billed per test and not per eye. The first quarter 2015 Medicare Physician Fee Schedule allowable is $35.04. Of this amount, $15.73 is assigned to the technical component of the test, and $19.31 to the professional component (i.e., interpretation). These amounts are modified by local wage indices so actual payment rates will vary. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.
SCODI-A 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 Is the physician’s presence required while SCODI-A is performed?
A No, under Medicare program standards, SCODI-A requires 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.
Q How frequently may this test be performed?
A Repeated testing is indicated when medically necessary for new symptoms, disease progression, new findings, or a change in the treatment plan. In general, additional testing is warranted when the information garnered from the eye exam is insufficient to adequately assess the patient’s disease.
Medicare utilization rates for claims paid in 2013 show that SCODI-A was performed in about 0.1% of all office visits by ophthalmologists. That is, for every 1,000 exams performed on Medicare beneficiaries, Medicare paid for this service once. For optometrists, it is twice as high.
Q If SCODI-A is performed for a non-covered indication, who is responsible?
A The beneficiary is financially responsible for non-covered services. Explain to the patient why SCODI-A is necessary and that Medicare will likely deny the claim. Ask the patient to assume financial responsibility for the charge and get his/her signature on an Advance Beneficiary Notice of Noncoverage (ABN) prior to performing the test. 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 re-fund the patient or show why Medicare paid in error.
Note that Medicare Advantage (MA) plans have their own versions of financial waiver forms that you must use for these patients instead of the ABN.
Q May 92020 (i.e., gonioscopy) be used to report imaging of the anterior chamber angle?
A No. Gonioscopy, as the term is commonly understood, does not include imaging. Note that SCODI-A means scanning computerized ophthalmic diagnostic imaging of the anterior segment.
Q If SCODI-A and SCODI-P are performed on the same day for the same patient, can both be reimbursed?
A In the current Medicare National Correct Coding Initiative (NCCI), SCODI-A and SCODI-P are not bundled so both codes may be billed when medically necessary. Other payers are not obliged to follow Medicare rules, and may have different guidelines.
Provided Courtesy of Visionix Inc. (800) 292-7468
Last updated January 22, 2015
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.
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