Code properly to avoid overpayment for this diagnostic technology.
The implementation of OCT-A in practice is similar to other new technologies: Technicians are often the first to learn about and use it. And success with the technology requires an understanding of what codes apply so that the office receives proper reimbursement, whether they are existing codes or new codes that have not been used previously.
How does the technology work?
The AAO’s web-based EyeWiki (a great resource for technicians) notes the following: “OCT-A technology uses laser light reflectance of the surface of moving red blood cells … eliminating the need for intravascular dyes … With OCT-A technology, the same tissue area is repeatedly imaged and differences analyzed between scans, thus allowing one to detect zones containing high flow rates (i.e. with marked changes between scans) and zones with slower, or no flow at all, which will be similar among scans.” Both swept-source (SS) — which uses a longer wavelength — and spectral-domain (SD) OCT instruments are capable of this.
OCT-A technology offers two main advantages: lack of an injection (safety for the patient) and shorter acquisition time to acquire the image needed. It’s not perfect for all situations — fluorescein and ICG-angiography are still needed for certain situations. OCT-A can introduce artifacts during capture due to media opacities, and superficial blood vessels can sometimes obscure deeper vessels that might be important in some diseases. Additionally, consider that some post-processing time for technicians is required after the test is completed on the patient.
What CPT code(s) apply?
I’m often asked about one of the codes below:
- 92235 – Fluorescein angiography (FA)
- 92240 – ICG angiography
- 92134 – SCODI (OCT) of the retina
- 92499 – Unlisted ophthalmological test or service
Since there is no fluorescein or ICG dye involved with OCT-A, codes 92235 and 92240 (and 92242, the new code for ICG and FA in 2017) cannot apply to OCT-A even though the term angiography is present. Code 92499 might apply if no other code applies, but it is clear that OCT-A should be “regular OCT of the retina” (92134).
The February 2011 issue of CPT Assistant contains a discussion of CPT code 92133 and 92134. It notes: “For the posterior segment, two distinct areas are imaged using the new technology, the optic nerve and the retina. The evaluation of the images differs. Consequently, codes 92133 and 92134 have been added to report scanning computerized ophthalmic diagnostic imaging of the optic nerve and retina, respectively ... Code 92134 describes scanning computerized ophthalmic diagnostic imaging of the retina.”
Medicare contractors and payers also provide guidance on what constitutes 92134. Palmetto GBA, a Medicare Administrative Contractor, notes the following in their Local Coverage Determination on this: “Scanning computerized ophthalmic diagnostic imaging (SCODI) is a noninvasive, noncontact imaging technique that produces high resolution images of ocular structures. These high resolution images are used to provide qualitative and quantitative data about the structural or physiologic properties of structures in the … posterior segment …” Other payers use similar language.
Although most patients clearly receive a “regular OCT of the retina” (and you would use 92134) on this day in addition to OCT-A, you cannot code 92134 twice. If you happen to have used the incorrect CPT 92499 for the OCT-A, then receiving payment on the same day as the already done and paid “regular OCT” via 92134 represents an overpayment for the 92499. This potentially puts your participation with the payer at risk, so don’t do it.
When is the patient responsible?
Sometimes the diagnosis code answer is not on a payer’s coverage listing, or you may do the test as screening. In both of those situations, the patient is responsible for payment if notified in advance and he consents to that arrangement before the test is done.
How should I discuss this with patients?
Be sure your patients who have had other angiograms know that there is no needle stick and no dye to color their skin or urine for a time. They should also know that, as a consequence of no dye, there can’t be an allergic reaction and that vomiting is highly unlikely. Don’t use your usual consent for FA or ICG angiography, which don’t represent what will occur.
The broad nature of the language for CPT 92134 means that it applies to OCT-A when performed. Don’t use or accept payment for 92499 — that potentially represents an overpayment with attendant risks.
As always, “good coding to you.” OP