Coding for Glaucoma &
Glaucoma Suspects
1
Coding for Glaucoma &
Glaucoma Suspects
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Glaucoma Risk Factors –
file://localhost/Users/alanhomestead/Documents/My
Documents A 2-25-13/Pathology, Education, Pharmaceuticals
8-15-08/Glaucoma/Tests Procedures/Risk/Glaucoma Risk
Factors.xls
2
Coding for Glaucoma &
Glaucoma Suspects
Office visit, 92 or 99
Frequency:
-As medically indicated (q 1mo, 3mo, 6mo, 12mo)
-No limit on office visits
3
Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
4
Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
Scanning computerized ophthalmic diagnostic
imaging,
92132 Anterior segment
92133 Posterior segment, optic nerve
92134 Posterior segment, retina
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Scanning Imaging
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian:
CGS:
WPS:
Novitas:
Palmetto:
Retired
Yes
Yes
Yes
No
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Scanning Imaging
Indications, Diagnosis Codes, Frequency
Medicare LCD
Retired LCD:
Guidelines not rules
List of ICDs handy
No LCD:
Clinical judgment allowed
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Scanning Imaging
Indications, Diagnosis Codes, Frequency
Medicare LCD
Diag. code = primary test of medical necessity
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Scanning Imaging
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
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Scanning Imaging
Interpretation & Report
Yes
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Scanning Imaging
Interpretation & Report - Medicare
Address the findings, relevant clinical issues,
and comparative data (when available)
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Scanning Imaging
Interpretation & Report
Suggestions:
• Succinct
• Test reliability (patient compliant, quality of
result)
• Results (better, worse or same)
• Noteworthy findings
• Diagnosis
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Scanning Imaging
Interpretation & Report
Suggestions:
• Impact on treatment
(no treatment, further test/surgery/consult,
continue/increase/decrease/stop/add meds)
• Impact on prognosis
• Physician signature
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Scanning Imaging
Interpretation & Report - Location
No requirement for specific location of I&R
I&R can be:
On the test printout/result
On a separate paper
In chart notes as discrete entry with other
E/M services
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Scanning Imaging
Interpretation & Report
Should be easily identified as I&R and not part
of exam
Should be readily available in case of audit
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Scanning Imaging
Unilateral / Bilateral
CPT: unilateral or bilateral
Medicare: Bilateral since 1/1/11
Non-Medicare: No universal rule, may follow
Medicare
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Scanning Imaging
CCI - Correct Coding Initiative
Code pairs which are not billed together
(usually)
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Scanning Imaging
CCI
92132 +
92133
92134
99211
(-59 ok)
(-59 ok)
(-59 ok)
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Scanning Imaging
CCI
92133 +
92132
92134
92250
99211
(-59 ok)
(-59 ok)
(-59 ok)
20
Scanning Imaging
CCI
92134 +
92132
92133
92250
99211
(-59 ok)
(-59 ok)
(-59 ok)
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Scanning Imaging
CCI Exceptions
Different anatomical site: R eye & L eye.
Different patient encounter on same day.
Different lesion (disease).
99211: Ok if extra tests ordered - VA, IOP, etc.
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Scanning Imaging
Doctor Order
Yes
Physician must clearly document in medical
record his intent that the test be performed
TC, 26 breakout indicates need for Doctor Order
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Scanning Imaging
Supervision Level
General
Responsible doc must be somewhere on earth, but
does not have to be in office
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Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
Pachymetry
76514
Ophthalmic ultrasound, diagnostic; corneal
pachymetry, unilateral or bilateral
(determination of corneal thickness)
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Pachymetry
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian: Retired
CGS:
Yes
WPS:
Retired
Novitas: No
Palmetto: Yes
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Pachymetry
Indications, Diagnosis Codes, Frequency
Medicare LCD
LCD may say:
Once in a lifetime for Glc. Susp.
No limit on non-glaucoma
Clinical judgment if no LCD
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Pachymetry
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
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Pachymetry
Interpretation & Report
No
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Pachymetry
Unilateral / Bilateral
CPT: unilateral or bilateral
however…
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Pachymetry
3rd Party Paying Unilaterally
(once each eye)
Cigna
First Choice
Regence – Blue Shield
Bill it twice w/ modifier RT & LT, & paid twice
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Pachymetry
3rd Party Paying Bilaterally
(once for both eyes)
Medicare
Aetna (1 per life glc & susp)
Premera – Blue Cross
UMP (1 per life glc & susp)
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Pachymetry
CCI
None
Doctor Order
Yes
Supervision Level
Does not apply
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Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
Visual Fields
92081 Limited
(tangent screen, Autoplot, arc perimeter, or single
stimulus level automated test)
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Coding for Glaucoma &
Glaucoma Suspects
Visual Fields
92082 Intermediate
(at least 2 isopters on Goldmann perimeter, or
semiquantitative, automated suprathreshold screening
program, Humphrey suprathreshold automatic
diagnostic test)
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Coding for Glaucoma &
Glaucoma Suspects
Visual Fields
92083 Extended
(Goldmann VF with at least 3 isopters plotted and static
determination within central 30 degrees, or
quantitative, automated threshold perimetry, Humphrey
full threshold 30-2, 24-2, or 30/60-2)
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Visual Fields
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian: Retired
CGS:
Yes
WPS:
Yes
Novitas:
Yes
Palmetto: No
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Visual Fields
Indications, Diagnosis Codes, Frequency
Medicare LCD
Clinical judgment if no LCD
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Visual Fields
Indications, Diagnosis Codes, Frequency NonMedicare
Every plan has own rules
Clinical judgment
May follow Medicare
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Visual Fields
Unilateral / Bilateral
CPT:
Unilateral or bilateral
Medicare: Bilateral, Payment same whether test
one or both eyes
Non-Medicare: No universal rule, may follow
Medicare
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Visual Fields
CCI
92081 +
92082
92083
99211
(-59 ok)
43
Visual Fields
CCI
92082 +
92081
92083
99211
(-59 ok)
44
Visual Fields
CCI
92083 +
92081
92082
99211
(-59 ok)
45
Visual Fields
Interpretation & Report
Yes
Doctor Order
Yes
Supervision Level
General
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Coding for Glaucoma &
Glaucoma Suspects
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
92250 Fundus photography
(no mention of instrument sophistication)
(no mention of angle or resolution)
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian:
CGS:
WPS:
Novitas:
Palmetto:
Retired
Yes
Retired
Yes
Yes
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Medicare LCD
Clinical judgment if no LCD
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Medicare LCD
LCD example:
“Fundus photo may be used for diagnosis of
macular degeneration, retinal neoplasms,
choroid disturbances, diabetic retinopathy,
glaucoma, multiple sclerosis, central
nervous system anomalies.” (CGS 2013)
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Medicare LCD
LCD example:
“to document a disease process, plan its
treatment, or follow progress of a disease”
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Medicare LCD
LCD example:
“not medically necessary simply to document
existence of condition. Photographs may be
medically necessary to establish baseline to
judge later whether disease is progressive.”
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Fundus Photo
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
54
Fundus Photo
Unilateral / Bilateral
CPT:
Silent
Medicare: Bilateral, Payment same whether one
or both eyes
Non-Medicare: No universal rule, may follow
Medicare
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Fundus Photo
CCI
92250 +
92133
(-59 ok)
92134
(-59 ok)
99211
(-59 ok)
Note: EO is not on CCI
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Fundus Photo
Interpretation and report
Yes
Doctor Order
Yes
Supervision Level
General
57
Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
92100
Serial tonometry (separate procedure) with
multiple measurements of IOP over an
extended time period, same day (eg,diurnal
curve or medical treatment of acute
elevation of intraocular pressure)
“Multiple” = ?
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Serial Tonometry
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian:
CGS:
WPS:
Novitas:
Palmetto:
No
No
No
No
No
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Serial Tonometry
Indications, Diagnosis Codes, Frequency
Medicare LCD
Clinical judgment if no LCD
61
Serial Tonometry
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
62
Serial Tonometry
Unilateral / Bilateral
CPT:
Silent
Medicare: Bilateral, Payment is same
whether test one or both eyes
Non-Medicare: No universal rule, may follow
Medicare
63
Serial Tonometry
CCI
92100 +
99211
(-59 ok)
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Serial Tonometry
Interpretation & Report
Yes
Doctor Order
No
Supervision Level
Concept does not apply
65
Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
92020 Gonioscopy (separate procedure)
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Gonioscopy
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian:
CGS:
WPS:
Novitas:
Palmetto:
Retired
No
No
No
No
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Gonioscopy
Indications, Diagnosis Codes, Frequency
Medicare LCD
Clinical judgment if no LCD
69
Gonioscopy
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
70
Gonioscopy
Unilateral / Bilateral
CPT:
Silent
Medicare: Bilateral, Payment is same
whether test one or both eyes
Non-Medicare: No universal rule, may follow
Medicare
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Gonioscopy
CCI
92020 +
92285
(-59 ok, add to 92020)
99211
(-59 ok)
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Gonioscopy
Interpretation and report
No
Doctor Order
No
Supervision Level
Concept does not apply
73
Coding for Glaucoma &
Glaucoma Suspects
Special Tests
Scanning Imaging (GDx, OCT)
Pachymetry
Visual Fields
Fundus Photo
Serial Tonometry
Gonioscopy
Extended Ophthalmoscopy
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Coding for Glaucoma &
Glaucoma Suspects
Ophthalmoscopy, extended, with retinal drawing
(eg, for retinal detachment, melanoma);
92225 initial
92226 subsequent
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Extended Ophthalmoscopy
Indications, Diagnosis Codes, Frequency
Medicare LCD
Noridian:
CGS:
WPS:
Novitas:
Palmetto:
Retired
Yes
Retired
Yes
Yes
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Extended Ophthalmoscopy
Indications, Diagnosis Codes, Frequency
Medicare LCD
Clinical judgment if no LCD
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Extended Ophthalmoscopy
LCD example:
- Initial and periodic evaluation of serious
internal eye disorders.
- Generally covered for neoplasms, retina
disorders, glaucoma, trauma, vitreous
disorders.
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Extended Ophthalmoscopy
LCD example:
- Stable conditions such as retinopathy in stable
diabetic may require only annual study while
acute intraocular infection may require weekly
studies.
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Extended Ophthalmoscopy
Indications, Diagnosis Codes, Frequency
Non-Medicare
Every plan has own rules
Clinical judgment
May follow Medicare
80
Extended Ophthalmoscopy
Unilateral / Bilateral
CPT:
Silent
Medicare: Unilateral, Bill separate for each eye,
RT & LT modifier
Non-Medicare: Typically unilateral
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Extended Ophthalmoscopy
CCI
92225 +
99211
(-59 ok)
92226 +
99211
(-59 ok)
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Extended Ophthalmoscopy
Interpretation and report
Yes
Doctor Order
No
Supervision Level
Concept does not apply
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Extended Ophthalmoscopy
Size & Color
-Palmetto: “minimum size of approximately 4
inches in diameter”
-CGS: “minimal size of 3-4 inches”
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AMD
file://localhost/Users/alanhomestead/Do
cuments/My Documents B 3-813/Adventures 11-3-12/O S/Presentations/Repository of My
PowerPoints/1 Topic Modules/AMD/AMD
Aug 13.ppt
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