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CODING Q&A: Coding for DR and OCTA

Sometimes diagnostic tests are billable to Medicare and other payers, sometimes they are not.

Last month, we looked at examples of coding scenarios for diagnostic tests for DR. This month, let’s continue the vignettes with another for DR testing with OCT angiography (OCTA).

Suzanne L. Corcoran, COE, is executive vice president and founder of Corcoran Consulting Group (CCG), San Bernardino, California, which specializes in coding and reimbursement issues for ophthalmic practices.

OCTA AND SCODI-P OF THE RETINA FOR DR

You are a retina specialist consulted by another eyecare provider concerning a 28-year-old man with blurred vision in both eyes; he is a Type I diabetic and takes insulin. He has had difficulty in the past with access to his veins. Your dilated fundus exam identifies proliferative DR in both eyes. You order SCODI-P of the retina and OCT angiography (OCTA) of the retina of both eyes and document your findings in your report. SCODI-P shows no DME. In addition to the exam (shown as 9xxxx), the claim will read as shown in Figure 1. Because both SCODI-P and OCTA are coded as 92134, it is reported only once.

Figure 1. Claim for SCODI-P and OCT angiography of the retina for DR. ICD-10 codes before and after October 1, 2016 dates of service differ because laterality was not part of diabetic codes until after October 1, 2016. Additionally, because type I diabetics (E10.- codes) are assumed to be on insulin by definition, the Z79.4 code for insulin is not used.

THE BIG PICTURE AND A LACK OF AGREEMENT

Many local coverage determinations for SCODI-P (scanning computerized ophthalmic diagnostic imaging, or OCT) focus on indications for the diagnosis and management of early glaucoma and optic nerve disease. As we know, SCODI-P is also an important tool in the detection and monitoring of many diseases of the vitreous, retina, and choroid. Many MACs have expanded the scope of indications to include them, although Medicare administrative contractors (MACs) and other payers do not all agree on a common list of diagnoses or technologies; review your payer policies.

OCTA is now available from several companies. Some use high-speed spectral-domain (SD) or swept-source (SS) technology to capture images, while other OCTA devices use split-spectrum amplitude-decorrelation angiography (SSADA) to detect movement in blood vessels. Analyzing motion within the retinal or choroidal blood vessels with OCTA creates images of vessels and capillaries, but does not require injection of dyes or contrast medium.

Prior to OCTA, ophthalmic angiography required intravenous injection of fluorescein or indocyanine green dye. Computed tomographic angiography in other parts of the body is performed with and without contrast material(s), and extending this approach to vessels in the eye is a welcome advancement.

OCTA captures images and, through additional analysis, creates detailed images of the blood vessels within the retina and choroid. So, broadly speaking, the term “angiography” is appropriate; however, the historic use of this term predisposes ophthalmic technicians, medical assistants, and billing staff to assume that dye is injected. Prior to OCTA, angiography of the retina and/or choroid required fluorescein or indocyanine green dye.

In CPT, fluorescein angiography is reported as 92235, and indocyanine green angiography is reported as 92240. The tests described by these codes require the use of intravenous dyes, so neither code is an accurate description of OCTA. According to the AAO’s coding program manager, OCTA should not be reported with other angiography codes of the eye that involve the use of intravenous dye.

Because OCTA provides additional information beyond traditional OCT of the retina and macula, it is more useful to the ophthalmologist or optometrist. From the patient’s perspective, avoiding an intravenous injection is preferable. So, the question is asked: “Can I use another CPT code, in addition to 92134, to describe the added utility of this service?” The code that is sometimes suggested is 92499, Unlisted ophthalmological procedure or service. Since 92134 does adequately describe OCTA, another CPT code is not necessary — it’s duplicative. An unlisted code is only used when a CPT code describing the service is not available. RP