CODING & REIMBURSEMENT

Fundus coding stays the same, despite technology

By Suzanne Corcoran

New technologies have reopened an old discussion about how practices should code fundus images taken with scanning laser technology. The difference in reimbursement has exacerbated the problem since Medicare pays much more for fundus photos. CPT Assistant, a publication of the American Medical Association, recently updated an instruction that should help resolve the controversy.

BACKGROUND

In April 1999, CPT Assistant published a Q&A on this topic. In summary, it asked whether it was appropriate to use CPT 92135 (scanning computerized ophthalmic diagnostic imaging, posterior segment) (SCODI-P) to describe a photo-type image obtained with a scanning laser. The answer was no; even when SCODI technology is used, CPT 92250 (fundus photography, more properly describes the end result. CPT 92135 has been discontinued, of course, and CMS replaced it with two codes for the posterior segment in 2011: 92133 SCODI-P, optic nerve and 92134 SCODI-P, retina. CPT Assistant revisited this discussion in the November 2014 issue. The answer did not change, but the discussion was interesting.

THE FINE DISTINCTIONS

If the scanning device creates an image of the optic nerve or retina as well as gives quantitative analysis of the nerve fiber layer thickness and other data, CPT 92133 or 92134 would be appropriate even if a photo-type image is also produced.

The CPT Assistant article says, “…if the only necessary service provided is generating a fundus photograph without the need to quantify the nerve fiber layer thickness … then reporting 92250 is appropriate, even if the photograph was taken with a scanning laser.” In addition, billing for the two SCODI-P codes and fundus photography in tandem has been much discussed. CPT includes a notation that it is inappropriate to bill 92133 and 92134 together for the same patient encounter. The CPT Assistant article notes that the same technician uses the same device at the same time to test the optic nerve and retina, so minimal practice expense is associated with the second test. The article does not address the physician’s time for the interpretation and report required of the codes, but it is clear that billing 92133 and 92134 together is not acceptable.

The codes are also mutually exclusive with one another and also with 92250 under Medicare’s National Correct Coding Initiative (NCCI) edits, although the NCCI edits show all three codes may be unbundled using modifier 59. Because you are taking the images for different diseases, the argument is that they should each be payable. Unfortunately, this is not acceptable for Medicare or other payers who follow Medicare guidelines. NCCI instructions state that modifier 59 is used to indicate a separate session or separate anatomical structure. There is no mention of separate disease, so modifier 59 would not be appropriate.