Coding Q&A

Understanding new OCT codes


Understanding the New OCT Codes: Answering Your Many Questions

Information provided by Riva Lee Asbell

Last month, we reviewed the basics of the new OCT codes for 2011. This month, I will answer some of the numerous questions that physicians, coders, billers and technicians have been asking.

Utilization Frequency:

Q. Regarding the change in billing OCT this year, we know the code is now unilateral or bilateral. Would it be acceptable to do and bill for one eye at the first visit and the second eye at the six-week follow-up visit? Have you seen any audits with other codes that are unilateral or bilateral?

A. No, you cannot code that way. This would be considered fraudulent coding. When a code descriptor states “unilateral or bilateral,” it does not make any difference if one or both eyes are tested — you code just one time for the test. Unilateral or bilateral is included in the code descriptors of visual fields and pachymetry and the coding is based on the same principle.

Q. How often can we do retina OCT testing?

A. This information is MAC-(Medicare Administrative Contractor) or carrier-dependent and is found in each contractor's Local Coverage Determination (LCD). If your contractor does not have one, I suggest you follow one of the others, such as Highmark Medicare or NGS Medicare for New York.

For example, the NGS Medicare policy states that, for retina diagnoses, four tests per year are appropriate but that patients with retinal conditions undergoing active intravitreal drug treatment may be allowed one scan per month per eye.

It also notes that these conditions include wet AMD, choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and non-proliferative), branch and central retinal vein occlusion, and cystoid macular edema. Also, other conditions that may undergo rapid clinical changes monthly, requiring aggressive therapy and frequent follow-up, such as macular hole and traction retinal detachment, may also require monthly scans.

Q. Where do I get the information on what ICD-9 Codes are covered?

A. That information is also listed in the LCD.

NCCI Bundles:

Q. Where can I find the rule regarding fundus photography and OCT not being allowed to be performed on the same day and if this can ever happen?

A. Fundus photos (CPT code 92250) and OCT for retina (CPT code 92134) are bundled mutually exclusively in the National Correct Coding Initiative. The national average payment for fundus photos is $73.38 and for OCT retina is $44.51. If both are coded together, the lowest-paying one is paid.

If both tests are medically necessary, technically you could bill only for the fundus photos; however, I caution you to be absolutely certain additional information is gained from each test. For those patients with choroidal neovascularization, for example, who have OCT scans done in conjunction with the determination of whether an injection should be performed or for monitoring the test, then the test that should be billed is the OCT.


Q. Do I need to use modifier 52 if I just do one eye?

A. Modifier 52 indicates reduced services and when a test considered inherently bilateral by Medicare, such as fundus photos, is performed on only one eye, it should be used. However, the code descriptor “unilateral or bilateral” overrides that, so for OCT do not use modifier 52.

Q. When we used the old code 92135, we always put RT or LT on the bill. Do we have to use any special modifiers for the new codes?

A. Modifiers are not required, but that depends on the LCD. Keep in mind that when the contractors updated their LCDs they may have just changed the code numbers without actually revamping the policy. Write to your Contractor Medical Director for up-to-date instructions. 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.