New coding rules and procedure codes for using OCT took effect January 1—here’s a quick review of what they mean.
The old CPT (Current Procedural Terminology) code of 92135 for ophthalmic diagnostic imaging—posterior segment—has been officially retired with the introduction of new codes designated by Medicare.
Billing Medicare for diagnostic imaging is now covered under three new optical coherence tomography (OCT) CPT codes (all codes are for “scanning computerized ophthalmic diagnostic imaging…with inter-pretation and report, unilateral, or bilateral”): 92132—anterior segment; 92133—posterior segment, optic nerve; and 92134 —posterior segment, retina.
The rules for using modifiers also have changed. RT and LT modifiers (for right and left eye, respectively) attached to the old 92135 code no longer apply. That’s because the new codes are for imaging one eye or both. The -52 modifier, indicating a reduced service, does not apply for these codes.
These three new codes obviously separate the procedure between the front and back of the eye. You may report imaging of the anterior segment and one posterior segment area for the same patient encounter. However, you may not report the optic nerve (92133) and retina (92134) for the same patient visit.
The bad news, according to my calculations of Medicare conversion factor and relative value units, is that the Centers for Medicate and Medicaid Services is reimbursing significantly less for OCT imaging this year—a national average of $45 for two eyes compared with an average of $90 in 2010.
FREQUENCY OF USE
Another issue to be aware of when using OCT is how frequently Medicare or a private payer will reimburse for the procedure in a year. In most states, you can bill for the procedure when it’s medically necessary, so your documentation should describe the medical reason for the test, a diagnosis with the appropriate code, and an interpretive report.
However, local coverage determinations (LCDs) in Medicare vary from state to state, so go to the Medicare Web site for your state to get an LCD list, including diagnosis codes. This can also serve as a guideline for private payers, but don’t be surprised if not all plans accept the same procedure or diagnosis codes, or both.
Medicare has also applied a rule prohibiting billing for scanning imaging in same patient encounter as ophthalmic photography (CPT code 92250).
• Performance of the procedure itself can be delegated to a technician, but the chart must include a doctor’s order for the test along with the doctor’s interpretive report. A standing order for performing OCT won’t pass muster with payers.
• The same billing rules apply whether you rent or borrow a scanner.
• Modifiers matter if you send a patient to a different office for the scan and you perform the interpretation and make the diagnosis. The scanning facility bills with the modifier—TC (for technical component) and you use modifier—26 (for the professional component).
• For Medicare patients, I recommend the referral facility also be a Medicare provider. If the imaging facility isn’t, you might get reimbursed but the facility might not.
• Supervision level for scanning codes is general, meaning the physician doesn’t have to perform the test but should be reachable by phone.
Finally, when it comes to setting OCT fees, set yours at the highest reimbursement level among your different payers. In many cases, this will be Medicare. If using OCT as a screening tool, then you can charge a fee that’s different (and probably lower) than the medically necessary fee.
Alan Homestead is an optometric physician practicing in Seattle and a consultant on coding issues and practice management.