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CODING Q&A: Testing and the Diabetic Patient

Exploring real-world coding examples.

Sometimes diagnostic tests are billable to Medicare and other payers, sometimes they are not. In this month’s column, I’ll focus on tests related to diabetes.

CODING REFRESH

Common tests ordered by retina specialists include scanning computerized ophthalmic diagnostic imaging (SCODI-P), OCT angiography (OCTA), fundus photography (FP), FP with autofluorescence (AF), fluorescein angiography (FA), and/or indocyanine green angiography (ICG) testing. The codes for these tests are presented in the table below.

92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
92242 Fluorescein angiography and indocyanine green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral (new code in 2017)
92250 Fundus photography with interpretation and report

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.

FROM THE PAGE TO THE PATIENT

We continue to receive questions about billing for these tests. Let’s explore real-world examples that will serve to illustrate common scenarios.

Diabetes With Retinopathy

Your 74-year-old Medicare patient with Type II diabetes on oral hypoglycemics presents for an examination after a 5-year lapse. You note mild nonproliferative DR in both eyes; at this time there is no DME in either eye. Importantly, prior exams were negative for diabetic changes. For a more detailed evaluation and to permit re-evaluation, you order and perform fundus photos. In addition to the exam (shown as 9xxxx), the claim will read as shown in Figure 1.

Figure 1. Diabetes with retinopathy claim. Note: For dates of service before October 1, 2016, the code would be E11.329 without the additional seventh character. Some payers may require the Z code for oral hypoglycemics, while others do not.

Fluorescein Angiography for DR

You are a retina specialist consulted by another eye care provider concerning a patient similar to that in the example above, but in this case you order FP and FA of the retina of both eyes and document your findings in your report. In addition to the exam (shown as 9xxxx), the claim will read as shown in Figure 2.

Figure 2. Claim for fluorescein angiography for diabetic retinopathy. Note: 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.

FA is a bilateral procedure in 2017; for dates of service before Jan. 1, 2017, it was a unilateral code. Fundus photography is not bundled with FA.

OCTA and SCODI-P of the Retina for DR

You are a retina specialist consulted by another eye care 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 OCTA of the retina of both eyes and document your findings in your report, and SCODI-P shows no DME. In addition to the exam (shown as 9xxxx), the claim will read as shown in Figure 3. Because both SCODI-P and OCTA are coded as 92134, it is reported only once. RP

Figure 3. Claim for OCTA and SCODI-P of the retina for diabetic retinopathy. Note: 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.