Medicare Reimbursement for SCODI of the Posterior Segment (Optovue)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR SCODI OF THE POSTERIOR SEGMENT
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Q What is SCODI of the posterior segment (SCODI-P)?
A Scanning computerized ophthalmic diagnostic imaging of the posterior segment (SCODI-P) is a diagnostic test that provides digital images of the fundus along with quantitative information such as length or depth. Optovue uses optical coherence tomography (OCT) to perform SCODI-P with iVue®, iScan™ and Avanti™.
Q What are the indications for SCODI of the posterior segment?
A There are a number of indications for SCODI-P, based on the medical necessity of the service. The list of valid diagnoses includes glaucoma and posterior segment disease such as exudative macular degeneration and diabetic retinopathy. Vascular images of the retina using SCODI (sometimes referred to as OCT angiography, or OCTA in this context) may be performed with AngioVue® software.
Q Is SCODI-P covered by Medicare?
A Medicare will reimburse you for SCODI-P if the patient presents with a complaint that leads you to perform this test as an adjunct to evaluation and management of a covered indication. 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 generally not covered (even if disease is identified). Also, it is not covered if performed for indication not in the local coverage policy. Local coverage policies vary so be sure to check your own Medicare contractor’s website.
Q What CPT code should we use to describe SCODI-P?
A There are two CPT codes to describe SCODI-P. 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 and the retina.
OCTA is coded as 92134 (not 92235 or 92240) since there is no injection of fluorescein or ICG dye with OCTA.
Q How much does Medicare allow for these tests?
A The Medicare Physician Fee Schedule allowable amounts for 2017 are:
Code Component Component Global
92133 $15.07 $22.97 $38.04
92134 $15.43 $26.20 $41.63
Since Medicare defines the test as bilateral, these amounts apply whether one or both eyes are tested, and are adjusted in each area by local indices. Other payers set their own rates, which may differ significantly from the Medicare fee schedule.
92133 and 92134 are 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 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, the medical record should include:
- order for the test with medical rationale
- date of the test
- the reliability of the test (e.g., cloudy due to cataract)
- test findings (e.g., fluid within the retina)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature
A form to document interpretation of these, and other, diagnostic tests is available here.
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 these tests. 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 Medicare administrative contractors (MACs) have published local policies that impose restrictions when performing SCODI-P with B-scan (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 How often may SCODI-P be repeated?
A In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.
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 92133, depending on the stage of glaucoma, and 92134 more often for some retinal diseases. 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.
Q How frequently is SCODI-P performed?
A CMS utilization rates for claims paid to ophthalmologists in 2015 show that 92133 was performed in conjunction with 9% of all exams. That is, for every 100 exams for Medicare beneficiaries, Medicare paid for this service nine times. For 92134, the 2015 utilization by ophthalmologists was 26%. For optometry, the utilization was 9% and 7%, respectively.
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.
Provided Courtesy of Optovue, Inc. (866) 344-8948
Last updated February 14, 2017
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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