CPT Coding for OCT Angiography

How do I report OCT angiography on a claim for reimbursement?

KIRK A. MACK, COMT, COE, CPC, CPMA

New technology typically creates questions about coding and reimbursement. Sometimes the new technology entails modest advances and does not require different CPT codes for billing; in other cases, it is significantly different and no existing CPT code will do. In this article, we discuss procedure coding for optical coherence tomography angiography (OCTA) and explain why a current CPT code, 92134, suffices to report OCTA on a claim for reimbursement.

NEW TECHNOLOGY

Several companies, including Optovue (Fremont, CA), Heidelberg Engineering (Franklin, MA), and Carl Zeiss Meditec (Dublin, CA), currently offer OCTA. An article in the International Journal of Retina and Vitreous describes OCTA as “a new, non-invasive imaging technique that generates volumetric angiography images in a matter of seconds.”

Some OCTA devices use high-speed spectral-domain or swept-source (SS) technology to capture images, while other OCTA devices use split-spectrum amplitude-decorrelation angiography (SSADA) to detect movement in blood vessels. Analyzing motion within the retinal or choroidal blood vessels with OCTA creates images of vessels and capillaries, but does not require injection of dyes or contrast medium.

Prior to OCTA, ophthalmic angiography required fluorescein or indocyanine green dye. Computed tomographic angiography in other parts of the body is performed with and without contrast material(s), so extending this approach to vessels in the eye is a welcome advancement.

TERMINOLOGY

In the context of OCTA, is the term “angiography” appropriate? Taber’s Medical Dictionary defines angiography in two ways:

1. A description of blood vessels and lymphatics

2. Diagnostic or therapeutic radiography of the heart and blood vessels with a radiopaque contrast medium. Types include magnetic resonance angiography, interventional radiology, and computed tomography.

OCTA captures images and, through additional analysis, creates detailed images of the blood vessels within the retina and choroid. So, broadly speaking, the term “angiography” is appropriate; however, the historic use of this term predisposes ophthalmic technicians, medical assistants, and billing staff to assume that dye is injected. Potential confusion on this point can and does lead to coding and billing errors.

CODING

In CPT, the first occurrence of the term “angiography” in the section devoted to Ophthalmology is 92235 - Fluorescein angiography, with interpretation and report. Next is 92240 – Indocyanine green angiography, with interpretation and report. Neither code is an accurate description of OCTA because neither fluorescein nor ICG dyes are used.

According to the AAO’s Coding Program Manager, OCTA should not be reported with 92235 or 92240, but with CPT 92134, Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina. This describes OCT of the retina and associated structures (eg, retinal layers, macula, retinal blood vessels).

The February 2011 CPT Assistant discusses CPT 92134. “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.”

In addition, a Medicare Administrative Contractor (MAC) National Government Services’ (NGS) Local Coverage Determination entitled Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI; L34380) defines it as:

“... a non-invasive, non-contact imaging technique. SCODI produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment disease ... SCODI also permits high resolution assessment of the retinal and choroidal layers, the presence of thickening associated with retinal edema, and of macular thickness measurement ...”

From these reliable sources, we conclude that 92134 should be used to report OCTA. The broad, inclusive language in the CPT description is sufficient for this purpose and the omission of the term “angiography” in CPT 92134 does not mean the descriptor should be narrowly construed or deemed insufficient. The general criteria for creation of a CPT code preclude fragmentation of an existing procedure reportable as a complete service by an existing code.

ANOTHER CODE?

Because OCTA provides additional information beyond traditional OCT of the retina and macula, it is more useful to the ophthalmologist or optometrist. From the patient’s perspective, avoiding an intravenous injection is preferable.

So the following question is asked: “Can I use another CPT code, in addition to 92134, to describe the added utility of this service?” The code that is sometimes suggested is 92499 — unlisted ophthalmological procedure or service.

Since 92134 does adequately describe OCTA, another CPT code is not necessary — it’s duplicative. An unlisted code is only used when a CPT code describing the service is not available.

OVERPAYMENT

Adding CPT code 92499 to a claim for 92134 represents a billing error. If the payer reimburses both procedures, it constitutes an overpayment; only 92134 should be reimbursed. If the third party payer pays 92134 and denies 92499, no overpayment exists.

However, collecting any additional payment from the beneficiary for 92499 is a fragmentation error, whether a financial waiver is used or not. An Advance Beneficiary Notice or similar document cannot be used to split a single complete service into two parts for the purpose of collecting additional payment from the beneficiary.

Under the provisions of the assignment agreement used by almost all ophthalmologists, the beneficiary is only responsible for copayments and deductibles associated with the covered service reported as 92134.

SUMMARY

OCTA represents an advance in the current ophthalmic imaging technology. It provides additional information, saves time, and lowers risk for the patient associated with intravenous injections of dye. Within CPT, 92134 is broadly defined so it includes OCTA. The coverage indications listed in Medicare local coverage determination policies and by third-party payers for CPT 92134 apply to OCTA. No other CPT code is needed, and collecting additional payment from the patient is problematic for many reasons. RP

REFERENCES