Coding & Reimbursement

Clarifying SCODI

By Suzanne L. Corcoran, COE

Scanning computerized ophthalmic diagnostic imaging (SCODI) for the posterior segment is a diagnostic test that has been available to ophthalmologists for years and continues to be valuable. There are a number of devices to perform SCODI, including but not limited to: GDx (Carl Zeiss Meditec, Dublin, Calif.), HRT (Heidelberg Engineering, Vista, Calif.) and Stratus OCT (Carl Zeiss Meditec), to name a few of the popular products.

Q. Does Medicare cover SCODI?

A. Medicare covers SCODI if the patient presents with a complaint that leads you to perform this test, or as an adjunct to management and treatment of a known disease. The list of valid diagnoses includes glaucoma and posterior segment disease such as macular degeneration. If the images are taken as baseline documentation of a healthy eye or as a preventative measure to screen for potential disease, then it is not covered (even if disease is identified).

Also, this test is not covered if performed for an indication that is not cited in the local contractor's coverage policy; check with your Medicare administrative contractor (MAC) for specific coverage limitations.

Q. What CPT code should we use to describe SCODI?

A. CPT code 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment, e.g., scanning laser, with interpretation and report) best describes this test. The phrase "posterior segment" was added to the definition in 2008. At the same time, a new Category III CPT code was introduced: 0187T (Scanning computerized ophthalmic diagnostic imaging, anterior segment with interpretation and report, unilateral). See my February 2008 column in OM for further information.

Q. What documentation is required in the medical record to support claims for SCODI?

A. Documentation requirements for SCODI are similar to those for other diagnostic tests. They include:

► an order for the test with medical rationale

► the date of the test

► the reliability of the test

► the test findings (e.g., cupping of optic disc)

► a diagnosis (if possible)

► the impact on treatment and prognosis

► the signature of the physician.

Q. Must the physician be present while SCODI is being performed?

A. Under the Medicare program standards, SCODI only needs general supervision. General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the test. The physician's prompt interpretation of the test results is still required, of course.

Q. Are there payment restrictions or bundles with 92135?

A. Medicare's National Correct Coding Initiative (NCCI) treats fundus photography (92250) as mutually exclusive with 92135. The E/M service 99211 is bundled with this test. In addition, several MACs have published local policies that impose restrictions when performing this test with B-scans (76512) and extended ophthalmoscopy (92225, 92226) unless for unrelated reasons. Some MACs and other third-party payers may question the need for visual fields and SCODI on the same day. Check your local coverage policies.

Medicare does not bundle this diagnostic test with physician office visits.

Q. How much does Medicare allow for 92135?

A. SCODI is defined as "unilateral," so reimbursement is per eye. The 2008 national Medicare Physician Fee Schedule allowable is $42.66. Of this amount, $25.52 is assigned to the technical component and $17.14 is the value of the professional component (i.e., interpretation). These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

Q. How often may this test be repeated?

A. In general, this and all diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.

Some MACs publish policies that provide upper limits on the number of tests that will be reimbursed in a year. Commonly, the policies state one or two times per year for glaucoma, and more often for some retinal diseases. Check your MAC's Web site for specific policies in your area. Too-frequent testing can garner unwanted attention from Medicare and other third-party payers. OM