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CODING Q&A: Coding for Optical Coherence Tomography Angiography

Confusion persists around what constitutes angiography.

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As optical coherence tomography angiography (OCTA) grows in prevalence in the retina community, coding questions arise. OCTA should be reported with CPT 92134 alone. No other CPT code suffices, and no additional CPT code is needed. As for some other questions, read on.

Q. What is OCTA?

A. According to one source, “Optical coherence tomography angiography (OCTA) is a new, non-invasive imaging technique that generates volumetric angiography images in a matter of seconds.”1

Several companies, including Optovue Corporation, Heidelberg Engineering, and Zeiss Medical Technology, currently offer OCTA devices. 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.2 Analyzing motion within the retinal or choroidal blood vessels with OCTA creates images of vessels and capillaries without the need for 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), so extending this approach to vessels in the eye is a welcome advancement.

Q. Is the term “angiography” appropriate?

A. Taber’s Medical Dictionary defines angiography in 2 ways:3

  1. A description of blood vessels and lymphatics
  2. Diagnostic or therapeutic radiography of the heart and blood vessels with a radiopaque contrast medium. Types include magnetic resonance angiography, interventional radiology, and computed tomography.

An OCTA scan captures images and, through additional analysis, creates detailed pictures 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 physicians and staff to assume that dye is injected. Potential confusion on this point can and does lead to coding and billing errors.

Q. What code(s) describes OCTA?

A. In CPT, fluorescein angiography is reported with 92235, and indocyanine green angiography is reported with 92240. The tests described by these codes use dyes, so neither code is an accurate description of OCTA. According to the American Academy of Ophthalmology’s Coding Program Manager, Sue Vicchrilli, OCTA should not be reported with 92235 or 92240, but with CPT 92134, Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina.4 This describes OCT of the retina and associated structures (eg, retinal layers, macula, retinal blood vessels).

Also, Medicare Administrative Contractor National Government Services’ Local Coverage Determination entitled Scanning Computerized Ophthalmic Diagnostic Imaging (L34380), defines SCODI as follows:

“… a non-invasive, non-contact imaging technique. SCODI produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment disease … SCODI also permits high resolution assessment of the retinal and choroidal layers, the presence of thickening associated with retinal edema, and of macular thickness measurement ...”5

From these reliable sources, we conclude that 92134 should be used to report OCTA. The broad, inclusive language in the CPT description is sufficient for this purpose and the omission of the term “angiography” in CPT 92134 does not mean the descriptor should be narrowly construed or deemed insufficient. The general criteria for creation of a CPT code preclude fragmentation of an existing procedure reportable as a complete service by an existing code.

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. Because 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.

Adding CPT code 92499 to a claim for 92134 would be a billing error. If the payer allowed both procedures, it constitutes an overpayment — only 92134 should be reimbursed. If the third-party payer pays 92134 and denies 92499, no overpayment exists. However, collecting any additional payment from the beneficiary for 92499 is a fragmentation error, whether a financial waiver is used or not. An ABN or similar document cannot be used to split a single complete service into 2 parts for the purpose of collecting additional payment from the beneficiary. Under the provisions of the assignment agreement used by almost all ophthalmologists, the beneficiary is only responsible for copayments and deductibles associated with the covered service reported as 92134. RP

REFERENCES

  1. de Carlo TE, Romano A, Waheed N, et al. A review of optical coherence tomography angiography (OCTA). Int J Retina Vitreous. 2015;1:5. Available at: https://journalretinavitreous.biomedcentral.com/articles/10.1186/s40942-015-0005-8 . Accessed Oct. 5, 2018.
  2. Yali J, Bailey ST, Hwang TS, McClintic SM, et al. Quantitative Optical Coherence tomography of vascular abnormalities in the living eye. Proc Natl Acad Sci USA. 2015. Available at: http://www.pnas.org/content/112/18/E2395.full.pdf . Accessed Oct. 5, 2018.
  3. Taber’s Medical Dictionary. http://www.tabers.com/tabersonline/view/Tabers-Dictionary/744098/all/angiography#10 . Accessed Aug. 29, 2018.
  4. 2018 Professional Edition CPT. Medicine/Ophthalmology, Special Ophthalmological Services. Page 619.
  5. National Government Services Inc. Local coverage determination. Scanning computerized ophthalmic diagnostic imaging (SCODI). L34380. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34380 . Accessed Aug. 29, 2018.