OCT and FP: Why can鈥檛 I bill both?

Fairly often, questions arise regarding the appropriate coding and billing of fundus photography, CPT 92250, and scanning computerized ophthalmic diagnostic imaging of the retina (SCODI-R), CPT 92134, also called retinal OCT. According to Medicare’s National Correct Coding Initiative (NCCI), these codes are considered mutually exclusive when performed on the same date of service; bill just one. We appreciate that some diagnostic technologies, such as scanning laser ophthalmoscopy (SLO), allow simultaneous capture of a fundus photography (FP) and optical coherence tomography (OCT) image. Choosing the code to submit on a claim for reimbursement requires some careful consideration. New instructions were published in CPT Assistant in December 2014 to guide the selection.

Billing Both OCT and FP

In 2000, the NCCI edits bundled the original SCODI code (CPT 92135) with fundus photography (FP) (CPT 92250). In 2011, a new SCODI code, 92134, was bundled with FP, 92250.1 A bundle means that just one service, usually the higher-reimbursed one, will be reimbursed when both are done on the same day. However, the NCCI edits are not absolute, and under some circumstances they do allow reimbursement for both services performed on the same day. According to the NCCI edits, the modifier indicator is “1”, so it is possible to unbundle SCODI-R and FP using modifier 59, subject to certain limitations.The General Correct Coding Policies for NCCI Policy Manual for Medicare Services2 discusses the column 1 and column 2 edits in the Mutually Exclusive Edit Table. It states:The CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together … Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment.Using modifier 59 to break the NCCI edit must be “clinically appropriate”.3  CMS published the Modifier 59 article providing further guidance on this issue. It states:Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.It further states: “Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site.” If FP and OCT are done in a single encounter, the use of modifier 59 precludes this guidance. Further, becausethe posterior segment  of the eyeis considered a contiguous structure, the guidance rarely supports breaking the NCCI edit.

Coding for SLO

In April 1999, CPT Assistant answered a question about proper coding for SLO.4 It stated:CPT 92135 Scanning computerized ophthalmic diagnostic imaging (eg, scanning laser) with interpretation and report, unilateral, is intended to report a method of objective measuring involving a quantitative determination of the thickness of the retinal nerve fiber layer and computer analysis of the data with the final results of creation of a database file, saving data for further comparing in follow-up examinations. It is not appropriate to assign CPT code 92135 for scanning laser fundus photography. CPT code 92250 Fundus photography with interpretation and report, that describes generation of retinal image only, and not data generation, would be appropriately assigned for this procedure.Fifteen years later in 2014, in the context of new technology that expanded the capabilities of SLO, the same question was posed to CPT Assistant. The answer, in the November 2014 issue,5 was different in a subtle and nuanced manner:Q: Is it appropriate to report CPT code 92135 (now codes 92133 and 92134) for this method of examination of the fundus?  A:  If the scanner produces an image of the retina or optic nerve along with other data and imaging for quantitative analysis, it would be appropriate to report a single service from the appropriate scanning computerized ophthalmic diagnostic imaging code range (92133-92134). If only an image is obtained then code 92250 would be reported.It goes on to explain that medical necessity of the FP or OCT service depends on what is needed rather than what is done.  It is important to note that if the only necessary service provided is generating a fundus photograph without the need to quantify the nerve fiber layer thickness and to analyze the data via a computer, then code 92250 is appropriate even if the photograph was taken with a scanning laser.

Pick Just One, But Which One?

When FP and OCT are performed concurrently, some billers routinely choose the test with the highest reimbursement, typically fundus photography, to submit on a claim. In light of the discussion here, that approach is too simplistic and ignores the medical necessity criterion. The individual condition of the patient is a better starting point when selecting which code to bill; the retina specialist should make the choice rather than depend on the biller to pick the code that represents more dollars. 

Conclusion

Advances in ophthalmic imaging, such as SLO, permit simultaneous capture of FP and OCT, but Medicare’s NCCI edits permit billing just one CPT code, 92250 or 92134, in most cases. Old instructions in CPT Assistant stipulated that 92250 is the correct code to report SLO. New instructions in December 2014 say it depends on whether qualitative or quantitative information is required for the patient’s condition. No single answer suits every situation; one needs to exercise clinical judgment to make an appropriate code selection.  RSMr. Mack is a senior consultant with the Corcoran Consulting Group. He is based in Galveston, Texas.

References1. CMS.gov. NCCI Coding Edits. Version 21.0. Effective January 1, 2015. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Accessed January 20, 2015.2. CMS.gov. NCCI Policy Manual for Medicare Services. Effective January 1, 2015. Chapter 1. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/01_overview.asp.  Accessed January 20, 2015. 3. CMS.gov. Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service. Updated 10/28/2014. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf. Accessed January 20, 2015. 4. Coding Clarification. Medicine Special Ophthalmological Services.  American Medical Association. CPT Assistant. April 1999; 10.5. Coding Clarification. Special Ophthalmological Services (92133, 92134). American Medical Association CPT Assistant.  November 2014;10.