92134_R23

1.  All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.

2.  Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The documentation must include the legible signature of the optometrist/ophthalmologist responsible for and providing the care to the patient.

3.  The submitted medical record should support the use of the selected ICD-10-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

4.  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.  Additionally, a copy of the test results, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams must be maintained in the patient’s file.

5.  If bilateral studies are reported, the documentation maintained by the provider must demonstrate medical need for the performance of the test for each eye.

6.  When reporting ICD-10 codes(s) Z79.891, Z79.899, Z09 or Z03.6, Z03.89, the medical record must reflect the medication administered as well as the underlying condition for which it was given.

1.  Report a Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment test with CPT code 92134 (retina).  This is a bilateral test, therefore no modifiers are required if both eyes are examined.  A unit of “1” is placed in the unit field of the CMS 1500 form or its electronic equivalent

2.  Scanning Computerized Ophthalmic Diagnostic Imaging Posterior Segment (retina) test requires general supervision by the optometrist/ophthalmologist.

3.  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.

4.  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.

Glaucoma

It is expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma.

Retinal Disorders

It is expected that only one exam/eye/2 months would be required to manage the patient whose primary ophthalmological condition is related to a retinal disease.  However, for those patients who are undergoing active treatment for macular degeneration or diabetic retinopathy one exam/eye/month may be appropriate for the management of their disease.

The use of fluorescein angiography, indocyanine green angiography and SCODI to study the patient’s same eye per clinical encounter will NOT be authorized.  However, SCODI and fluorescein angiography may be obtained on the patient’s same eye per clinical encounter if the medical record substantiates the need for both studies.