Medicare Reimbursement for SCODI of the Posterior Segment (Optos)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR SCODI OF THE POSTERIOR SEGMENT
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Q What is the Optos® Monaco Ultra-widefield imaging and OCT imaging system?
A According to Optos, it is a 200 degree single capture retinal imaging system with ultra-widefield color depth imaging and autofluorescence (FAF) combined with integrated OCT. High resolu-tion single capture improves pathology detection and disease management. Central pole OCT provides comprehensive multi-modal imaging with automated protocols which enable super-fast image capture.
Q Does Medicare cover SCODI of the posterior segment (SCODI-P)?
A 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 the test 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 contractor’s coverage policy. Check with your Medicare Administrative Contractor (MAC) for specific coverage limitations.
Q What are the indications for SCODI-P?
A Medicare will reimburse for SCODI-P based on the medical necessity of the service. The list of valid diagnoses includes glaucoma and pos-terior segment disease such as exudative macular degeneration. Local policies vary so check your own Medicare contractor’s website.
Q What documentation is required in the medical record to support claims for SCODI-P?
A A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images or a reference to where they are stored, the medical record should include:
- order for the test with medical rationale
- tate of the test
- The reliability of the test (if compromised)
- test findings (e.g., printout of OCT)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
A form suitable for documenting the interpretation of fundus photos and other tests is available on our website. It may also be adapted for use within an EMR system.
Q What CPT code should we use to describe SCODI-P?
A There are two CPT codes to describe SCODI-P.1 They are:
- 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.
Note the distinction between a test performed on the optic nerve (usually glaucoma) and the retina (retinal or macular diseases such as AMD or diabetic retinopathy).
Q How much does Medicare allow for this test?
A The 2018 Medicare Physician Fee Schedule allowable amounts are:
Since Medicare defines the test as bilateral, these amounts apply whether one or both eyes are tested. Actual payments are adjusted in each area by local indices. Other payers set their own rates, which may differ significantly from Medicare fees.
92133 and 92134 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 What payment restrictions or bundles exist with SCODI-P and other ophthalmic services?
A 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. CPT also notes that 92133 and 92134 may not be reported at the same patient encounter and Medicare has imposed the same edit, even if performed for different diagnoses.
Several MACs have published local policies that impose restrictions when performing SCODI-P with B-scans (76512) and extended ophthalmoscopy (92225, 92226) unless for unrelated reasons. Some MACs and other third party payers have also questioned the need for visual fields and SCODI-P on the same day. Check your local coverage policies.
Q Is the physician’s presence required while SCODI-P is being performed?
A Under Medicare program standards, this test 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 procedure.
Q How often may SCODI-P be repeated?
A In general, diagnostic tests are reim-bursed when medically indicated. Clear documen-tation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.
In 2016, the CMS ophthalmology utilization rate for 92133 was 9%. That is, for every 100 exams for Medicare beneficiaries, Medicare paid for this service nine times. For 92134, the 2016 utilization was 28%. Optometric utilization was about 7% for each test.
Some MACs publish policies that provide upper limits on the number of tests that will be reimbursed in a year. Commonly, the policies state 1 or 2 times per year for glaucoma (92133), and more often for some retinal diseases (92134). Check your MAC’s website for specific policies in your area. Too-frequent testing can garner unwanted attention from Medicare and other third party payers.
1 CPT Assistant. Coding Clarification: Special Ophthal-mological Services (92133, 92134). Nov. 2014. p.10
Provided Courtesy of Optos, Inc. (800) 854-3039
Last updated May 8, 2018
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including 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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