January 1, 2025, ushered in a new CPT code: optical coherence tomography angiography (OCTA), 92137. However, clear guidelines for its use and documentation are still lacking. Medicare Administrative Contractors (MACs) have OCTA under the same SCODI category as retinal OCT (92134), but there is no specific guidance to ensure proper utilization, medical necessity, and documentation requirements. This Q&A integrates coding reasoning with known policy guidelines for SCODI to assist in navigating appropriate use.
Q: When should OCTA be used instead of retinal OCT?
A: Monitoring for intravitreal injection needs is usually performed using retinal OCT. However, if OCTA is medically necessary, its use must be documented and justified within the treatment plan. The reasons for its necessity and how it influenced the treatment should be clearly recorded in the impression or plan.
Q: How frequently can practices perform OCTA?
A: Since the MACs now include OCTA under the same SCODI framework as retinal OCT, its use is generally acceptable about once per month during active treatment. For patients not in active treatment, utilization should usually not be more frequent than every 2 months, with documentation clearly showing the clinical change or decision point that requires imaging. Routine monthly OCTA in stable or minimally changing disease should be approached with caution, as medical necessity might be questioned.
Q: What should be documented in the chart to support OCTA?
A: Document the reason OCTA is medically necessary for today’s diagnosis and treatment decision instead of a retinal OCT alone. The interpretation and report should include relevant findings from the day’s OCTA-driven evaluation, along with pertinent retinal OCT information, and clearly explain how these findings influence the treatment plan. Like most diagnostic tests, there should be an order specifying the exact test, indication, and eye(s) to be imaged. Additionally, ensure that the images are stored in the record or image repository.
Q: Which NCCI edits relate to OCTA?
A: According to the National Correct Coding Initiative (NCCI), OCTA is bundled with optic nerve OCT and retinal OCT and cannot be unbundled with a modifier. Starting October 1, 2025, OCTA is also bundled with eye codes, fluorescein angiography (FA), indocyanine green angiography (ICG), and FA/ICG if performed on the same day. Although the edit can be unbundled using a modifier, caution should be exercised. Confirm that documentation and medical necessity are in place before adding a modifier to the OCTA. Currently, it is unknown whether these edits were in error.
Q: What are the most common reasons for denials?
A: The reasons for denials are usually a lack of medical necessity and supporting documentation. Cloned or copy-pasted interpretations, missing orders, or missing elements for the order—such as the specific test, the indication for the test, or the eye(s)—can all cause denials. Additionally, the utilization or frequency of the OCTA can be an additional factor. The key is to focus on medical necessity for the information the test will provide, rather than ordering an OCTA routinely. RP
