Reimbursement for OCT Exams
PROVIDED BY RIVA LEE ASBELL
How can I get paid for OCT exams? The retina diagnoses are not in my carrier's local
A. Practices can easily bill for optical coherence tomography
(OCT) if their Medicare carrier has incorporated the retinal diagnoses into the
local coverage determination (LCD) formerly known as LMRP (Local Medical Review
Policy). Payment becomes problematic when the Medicare carrier has not incorporated
the diagnosis into its policy, and thus the computer rejects the claim as not having
a payable diagnosis.
OCT meets the generic description of CPT code 92135, scanning
computerized ophthalmic diagnostic imaging (SCODI), and may be billed using that
code when the carrier has included the proper retinal diagnoses in the approved
lists of diagnoses. If your carrier has not done this, the claim will be rejected.
Do not use a wrong diagnosis just to engender payment. Many carriers have included
OCT-applicable diagnoses in their SCODI policies.
Be sure to check your LCD or LMRP; it may be listed under optical
coherence tomography, scanning glaucoma laser tests (SGLT), SCODI, or laser
If your carrier has not revised its policy and does not include
the applicable diagnoses, you certainly can try billing it with the unlisted diagnostic
test procedure code 92499. I suggest attaching a letter explaining why this
should be paid and citing other Medicare carriers that have adjusted their policies
(Cigna North Carolina, National Heritage Insurance Company, Wisconsin Physicians
Service Insurance Corporation, and Noridian).
It might also be worthwhile to go through the CAC (Carrier Advisory
Committee) and have them request the carrier medical director to get the policy
changed. I did this for Cigna North Carolina. It took a long time, but the policy
Q. Could you clear up the new ultrasound codes? Do I have to keep
an image in the chart?
A. The ophthalmic ultrasound codes were revised in 2005 to distinguish
between B-scans that merely have a superimposed A-scan on the screen and a true
diagnostic A-scan that is used for measurement and evaluation of ocular pathology
such as intraocular tumors.
The new/revised codes now read:
- 76510: ophthalmic ultrasound, diagnostic:
B-scan and quantitative A-scan performed during the same patient encounter
- 76511: quantitative A-scan only
- 76512: B-scan (with or without a superimposed
Diagnostic quantitative A-scan is a special test performed in
a few centers, primarily by those who specialize in ultrasonography. It is generally
used in evaluating intraocular lesions and a few other problematic diagnoses. Different
probes are used in this procedure. It is not to be used when an IOL measurement
and B-scan are both performed on the same day. There has already been much confusing
advice and interpretation on this. The new code emerged from some bundling issues
that recurred, but its utilization should be limited to when those specific services
In order to clarify the interpretation and report requirements
for diagnostic radiology procedures, new introductory remarks were published in
the 2005 CPT.
All diagnostic ultrasound examinations require permanently recorded
images with measurements, when such measurements are clinically indicated. For those
codes whose sole diagnostic goal is a biometric measure (ie, 76514, 76516, and 76519),
permanently recorded images are not required. A final, written report should
be issued for inclusion in the patient's medical record. The prescription form for
the IOL satisfies the written report requirement for 76519.
What many providers have failed to realize is that the Radiology
Guidelines that preface the codes in CPT state the following: "A written report,
signed by the interpreting physician, should be considered an integral part of a
radiologic procedure or interpretation." This differs from "with interpretation
and report" that is included in the code descriptor of the codes found under
Special Ophthalmologic Services.
CPT codes copyright 2004 American Medical Association
Riva Lee Asbell is the principal in Riva Lee
Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be
reached through her Web site at
Retinal Physician, Issue: September 2005