Obtaining Reimbursement for OCT Exams

Obtaining Reimbursement for OCT Exams

Q. How can I get paid for OCT exams? The retina diagnoses are not in my carrier's local policy.

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 coherence tomography.

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 was changed.

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 non-quantitative A-scan).

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 are performed.

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