Coding Q&A

Trying to “end run” new OCT coding? A bad idea you should not pursue


Trying to “End Run” New OCT Coding? A Bad Idea You Should Not Pursue

Information Provided By Riva Lee Asbell

Asense of desperation surrounds the reimbursement cuts for OCT. It is reflected in the questions now being posed to consultants and in the comments posted on listservs. These are all attempts to embrace erroneous ideas for avoiding the cuts.

Here, I'll discuss the current coding guidelines for OCT and fundus photographs in the context of treating wet macular degeneration using intravitreal injections.

Fundus photos and OCT are bundled under the National Correct Coding Initiative when performed on the same day. The most dangerous comments suggest billing for fundus photos instead of OCT because the reimbursement for the latter is double. A sampling reveals comments such as, “Just bill for the photos when both photos and OCT are done since they're bundled and you can't collect for both” and “Another retina practice suggested that we unbundle OCT and fundus photos done on the same day using the 59 modifier. They state that if we have medical necessity for both tests, and interpret both separately, we are allowed to unbundle.”

The key words are “medical necessity.” One of the best explanations was written by Michael K. Rosenberg, MD, who was the Medicare Carrier Medical Director, Michigan, in the February 2002 issue of the Medicare Bulletin for Michigan and Illinois.

Dr. Rosenberg wrote:

“The implication inherent in a medical necessity denial is that the diagnostic or therapeutic service provided by the physician was unnecessary, and, therefore, in some way bad or at the very least superfluous … What is not appreciated is that Medicare has evolved, over the years, into a very defined benefit program. In Medicare terms, “not medically necessary” simply means that the service is not a benefit under this defined benefit, for this diagnosis, at this time. Time and diagnosis are the key words, in that neither is immutable. A given procedure may become medically necessary, for a given diagnosis, at future time, and vice versa … It is important to remember that the phrase is not a value judgment regarding the provider's (competence).”

This concept is as valid today as when it was written. Let's see how it applies to OCT and fundus photos. Coding advice similar to what I quoted earlier borders on fraudulent coding and billing and the core issue is total disregard for medical necessity.

It is OCT results that were used in gauging the effectiveness of treatment with intravitreal injections (bevacizumab/ranibizumab) in the various clinical trials. Thus, the medical necessity of the test itself is validated as is its use as the primary diagnostic test.

Jason Slakter, MD, states, “OCT is the major method of evaluating the status of the macula for ongoing therapy of AMD. However, there may be reasons for doing a color photo on the same visit, including documentation of the presence/absence of pigment, lipid, blood in the macula; documentation of the status of the optic nerve; or for more careful evaluation of any of the features above or other items that may be seen or suspected on the clinical exam.”

When a patient is being evaluated for whether or not an intravitreal injection should be given based on the OCT findings, then that becomes the test for which there is primarily medical necessity; the fundus photos have only a secondary role, if any, in the medical decision making. Without the OCT, the decision simply cannot be made. Do not unbundle fundus photos and OCT.

Furthermore, if the office visit is going to be billed on the same day as the injection by using modifier 25, then the OCT becomes the diagnostic test for which there is the medical necessity.

In addition, there must be medical necessity for performing the fundus photos on the same day. You cannot order fundus photos simply to bill them instead of the OCT. RP

CPT codes ©2011 American Medical Association.

Riva Lee Asbell can be contacted at, where the order form for her new book, Tips on Ophthalmic Surgical Coding by Subspecialty, can be found and downloaded under Products/Books.