Medicare Reimbursement for SCODI of the Posterior Segment (ZEISS)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR SCODI OF THE POSTERIOR SEGMENT (ZEISS)

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Q: Does Medicare cover SCODI of the posterior segment with Cirrus HD-OCT?

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).[1] 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

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 eligible diagnoses is lengthy and includes glaucoma, macular degeneration, and other posterior segment diseases. Payer policies vary significantly.

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

A: In addition to the images, 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:

an order for the test with medical rationale
the date of the test
the reliability of the test
the test findings (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

Document the location of the images if they are stored separately from the medical record.

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: How much does Medicare allow for this test?

A: The 2019 national Medicare Physician Fee Schedule allowable amounts are:

Technical Professional

Code Component Component Global

92133 $15.14 $22.70 $37.84

92134 $15.50 $26.31 $41.81

Since Medicare defines these tests as bilateral, the amounts apply whether one or both eyes are tested. 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: What payment restrictions or bundles exist between SCODI-P and other ophthalmic services?

A: 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) have published policies that impose other restrictions when performing SCODI-P with B-scans (76512) and extended ophthalmoscopy (92225, 92226). Check your payer policies; they vary.

Q: How often may SCODI-P be repeated?

A: 92133 is generally allowed once per year for glaucomatous patients, and then usually for early or moderate disease. It is used far less frequently in severely advanced glaucoma. 92134 is allowed more often – typically up to 4 times per year – or monthly in patients with retinal conditions undergoing active intravitreal drug treatment. Clear documentation of the reason for testing is always required.

CMS utilization rates for claims paid in 2017 show that 92133 was associated with 9% of all ophthal-mology office visits. That is, for every 100 exams for Medicare beneficiaries, Medicare paid for this service 9 times. For 92134, the utilization was 29%. For optometry, the utilization was about 7% each.

Q: What is the frequency of SCODI-P in the Medicare program?

A: CMS utilization rates for claims paid in 2016 show that 92133 was associated with 9% of all ophthalmology office visits. That is, for every 100 exams for Medicare beneficiaries, Medicare paid for this service 9 times. For 92134, the 2016 utilization was 28%. For optometry, the utilization was about 7% for each code.

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

A: Explain why SCODI-P is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility. 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] An exception is monitoring for ophthalmic pathology in patients on long-term therapy with high-risk medications, such as Chloroquine/hydroxy chloroquine. For more information, please request Corcoran’s FAQ on Plaquenil (Link here).

Provided Courtesy of ZEISS

Last updated March 13, 2019

The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, etc.

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. 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.

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