Print | ShareCPT Code: 92133 Region: 05
States covered: Florida, Puerto Rico, Virgin Islands
Title: Scanning Laser - Posterior Segment (Optic Nerve)
Category
Special Ophthalmological Services
Description
Scanning computerized ophthalmic diagnostic imaging, posterior segment - optic nerve, unilateral or bilateral
Many forms of scanning computerized ophthalmic diagnostic imaging (SCODI)tests currently exist (e.g., confocal laser scanning ophthalmoscopy (topography), scanning laser polarimetry, optical coherence tomography (OCT), and retinal thickness analysis). Although these techniques are different, their objective is the same.
Confocal scanning laser ophthalmoscopy (topography) uses multiple tomographic images to make quantitative topographic measurements of either the optic nerve head or posterior retinal structures to detect glaucomatous damage to the nerve fiber layer of the retina or non-glaucomatous retinal changes in the microstructure of the posterior retina (e.g. macular edema, atrophy associated with degenerative retinal diseases).
Scanning laser polarimetry measures change in the linear polarization of light (retardation). It uses a polarimeter, an optical device to measure linear polarization change and a scanning laser ophthalmoscope together to measure the thickness of the nerve fiber layer of the retina.
Optical coherence tomography is a non-invasive, non-contact imaging technique. It produces high-resolution, longitudinal, cross-sectional tomographs of ocular structures to detect evidence of glaucomatous damage or subsurface retinal defects.
Retinal thickness analysis is a computerized slitlamp biomicroscope that is intended to provide manual and computerized tomography of the retina in vivo to determine the thickness and the inner structure of the retina. It is indicated for assessing the area and location of retinal thickness abnormalities, such as thickening due to macular edema and atrophy associated with degenerative diseases, and for visualizing other retinal pathologies.
Posterior segment SCODI allows for early detection of glaucomatous damage to the nerve fiber layer or optic nerve of the eye. It is the goal of these diagnostic imaging tests to discriminate among patients with normal intraocular pressures (IOP) who have glaucoma, patients with elevated IOP who have glaucoma, and patients with elevated IOP who do not have glaucoma. These tests can also provide precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of follow-up exams than visual field and/or disc photos. This can allow earlier and more efficient efforts of treatment toward the disease process.
Retinal disorders are the most common causes of severe and permanent vision loss. SCODI is also used for the evaluation and treatment of patients with retinal disease, especially certain macular abnormalities. It details the microscopic anatomy of the retina and the vitreo-retinal interface.
Posterior segment SCODI will be considered medically reasonable and necessary under the following circumstances:
1. The patient presents with “mild” glaucomatous damage or “suspect glaucoma” as demonstrated by any of the following:
- Intraocular pressure ³ 22mmHg as measured by applanation
- Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio > 0.4
- Diffuse or focal narrowing or notching of disc rim, especially at inferior or superior poles
- Diffuse or localized abnormalities of the retinal nerve fiber layer, especially at the inferior or superior poles
- Nerve fiber layer disc hemorrhage
- Asymmetrical appearance of the optic disc or rim between fellow eyes that suggests loss of neural tissue
- Nasal step peripheral to 20 degrees or small paracentral or arcuate scotoma
- Mild constriction of visual field isopters
Because of the slow disease progression of patients with “suspect glaucoma” or those with “mild” glaucomatous damage, the use of scanning computerized ophthalmic diagnostic imaging at a frequency of > 1/year is not expected.
2. The patient presents with “moderate” glaucomatous damage as demonstrated by any of the following:
- Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio > 0.5 but < 0.8
- Definite focal notch with thinning of the neural rim
- Definite glaucomatous visual field defect (e.g., arcuate defect, nasal step, paracentral scotoma, or general depression)
Patients with “moderate damage” may be followed with scanning computerized ophthalmic diagnostic imaging and/or visual fields. One or two tests of either per year may be appropriate. If both scanning computerized ophthalmic diagnostic imaging and visual field tests are used, only one of each test would be considered medically necessary, as these tests provide duplicative information.
Scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary for patients with “advanced” glaucomatous damage. Instead, visual field testing should be performed. (Late in the course of glaucoma, when the nerve fiber layer has been extensively damaged, visual fields are more likely to detect small changes than scanning computerized ophthalmic diagnostic imaging).
The patient with “advanced” glaucomatous damage would demonstrate any of the following:
- Diffuse enlargement of optic nerve cup, with cup to disc ratio > 0.8
- Wipe-out of all or a portion of the neural retinal rim
- Severe generalized constriction of isopters (i.e., Goldmann I4e ,< 10 degrees of fixation)
- Absolute visual field defects to within 10 degrees of fixation
- Severe generalized reduction of retinal sensitivity
- Loss of central visual acuity, with temporal island remaining
In addition, scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary when performed to provide additional confirmatory information regarding a diagnosis which has already been determined.
3. Monitoring patients for the development of chloroquine (CQ) and/or hydroxychloroquine (HCQ) retinopathy. Patients being treated with CQ and/or HCQ should receive a baseline examination within the first year of treatment and as an annual follow-up after five years of treatment. For higher-risk patients, annual testing may begin immediately (without a 5-year delay).
4. The evaluation and treatment of patients with retinal disease (e.g., macular degeneration, diabetic retinopathy) and in the evaluation and treatment of certain macular abnormalities (e.g. macular edema, atrophy associated with degenerative retinal diseases).
ICD-10 Diagnosis Codes
ICD-10 Codes Asterisk Explanation: *Additional ICD-10 CM codes Z03.89, Z09, Z79.84 and Z79.899 that apply to CPT code 92134 only. Note: ICD-10 CM Code Z03.89 applies only when testing is necessary prior to the start of chloroquine (CQ) and hydroxychloroquine (HCQ) therapy.
1. Medical record documentation (e.g., office/progress notes) maintained by the performing physician must indicate the medical necessity of the scanning computerized ophthalmic diagnostic imaging and be available to Medicare upon request.
2. A copy of the test results, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams is required.
3. Medical record documentation must clearly indicate rationale which supports the medical necessity for performing the fundus photography and posterior segment SCODI on the same day on the same eye. Documentation should also reflect how the test results were used in the patient’s plan of care.
4. It would not be considered medically reasonable and necessary to perform fundus photography and posterior segment SCODI on the same day on the same eye to provide additional confirmatory information for a diagnosis or treatment which has already been determined.
1. Report a Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment test with CPT code 92133 (optic nerve). This is a bilateral test, therefore no modifiers are required if both eyes are examined. A unit of “1” should be placed in the unit field of the CMS 1500 form or its electronic equivalent.
2. If only one eye is examined, the -RT or -LT modifier should be applied to the service line. A unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent.
3. Scanning Computerized Ophthalmic Diagnostic Imaging Posterior Segment (retina) test requires general supervision by the optometrist/ophthalmologist.
4. An eye examination may be reported on the same day with Scanning Computerized Ophthalmic Diagnostic Imaging Posterior Segment (retina) test if it is medically necessary.
5. Scanning Computerized Ophthalmic Diagnostic Imaging Posterior Segment (retina) (92134) and Scanning Computerized Ophthalmic Diagnostic Imaging Posterior Segment (optic nerve) (92133) can not be billed on the same day regardless of diagnosis.
Performing Fundus Photography and SCODI on the Same Day on the Same Eye
Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier -59-distinct procedural service or HCPCS modifier XU-unusual-non-overlapping service to CPT code 92250.
The optometrist/ophthalmologist is not precluded from performing fundus photography and posterior segment SCODI on the same eye on the same day under appropriate circumstances (i.e., when each service is necessary to evaluate and treat the patient.
Fundus photography and posterior segment SCODI will be considered medically reasonable and necessary when performed on the same eye on the same day as outlined below.
Fundus photography and Posterior Segment SCODI are frequently used together for the following diagnoses:
B39.4
C69.30–C69.32
D18.09
D31.30–D31.32
E08.311–E08.359
E09.311–E09.359
E10.311–E10.359
E11.311–E11.359
E13.311–E13.359
H30.001–H30.93
H31.001–H31.129
H31.22
H31.321–H31.329
H31.401–H31.429
H32
H33.001–H33.059
H33.101–H33.119
H33.191–H33.199
H33.20–H33.23
H33.301–H33.339
H33.40–H33.42
H33.8
H34.10–H34.13
H34.231–H34.239
H34.811–H34.839
H35.00–H35.09
H35.20–H35.23
H35.30–H35.389
H35.50–H35.54
H35.60 –H35.63
H35.70–H35.739
H35.81
H35.89
H36
H44.20–H44.23
H44.40–H44.449
H59.031-H59.039
Q14.8
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.