Medicare Reimbursement for SCODI of the Posterior Segment (Swept Source OCT)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR SCODI OF THE POSTERIOR SEGMENT(Swept Source OCT)

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Q: Does Medicare cover SCODI of the posterior segment with Topcon’s DRI OCT-1 Atlantis?

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 DRI OCT-1 is a swept source OCT which utilizes different technology and faster scanning speeds to reduce the effect of eye movement; however, CPT coding is the same as other SCODI-P instruments.1
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 claims 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

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 2017 national Medicare Physician Fee Schedule allowable amounts are:

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) 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. 92134 is allowed more often – typically up to 4 times per year – or once per month in patients with retinal conditions undergoing active intravitreal drug treatment.2 Clear documen-tation of the reason for testing is always required. Too-frequent testing can garner unwanted attention.

Q: How frequently is SCODI-P performed?

A: CMS utilization rates for claims paid in 2015 show that 92133 was performed in 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 2015 utilization was 26%. For optometry, the utilization was 9% and 6%, respectively.

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

Last updated January 01, 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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