The boom in diagnostic instrumentation over the past decade has provided incredible tools for eye doctors to better manage their patients’ eye care needs. Plus, this advanced technology simply makes medical eye care more exciting and fun.

However, more tools in our toolbox means that optometrists have to be better aware of the proper use, billing and coding of this technology. Let’s review some of this new technology.

Ocular Blood Flow
Perfusion of the optic nerve was cited by the World Glaucoma Association as one of the most important concepts in our future understanding and management of glaucoma.¹ While clinical models that measure ocular blood flow are limited, they are becoming more widely available. The Centers for Medicare & Medicaid (CMS) has recognized the application of this technology, but has assigned it a Level III CPT code (0198T) that does not mandate reimbursement. With a recommended Advanced Beneficiary Notice (ABN), providers can always bill the patient directly. Payment policy from other medical payers is highly variable.

Wavefront Analysis
Instruments measuring high-order aberrations are becoming more common and affordable. Although options for reducing vision problems induced by high-order aberrations are still limited, wavefront analysis can provide the data needed to answer perplexing vision complaints, including reduced vision with no apparent reason and persistent symptoms after refractive or intraocular surgery. Often, the answer is a simple cure for the patient’s symptoms or concerns. Currently, this technology has not been recognized by the assignment of a CPT code, but providers can always elect to bill the patient for this valuable service.

Visual Evoked Potential
Electrodiagnostic testing of the vision system is not new technology, but electrodiagnostic instrumentation that is clinically usable and affordable is. Select visual evoked potential (VEP) analysis can now be performed on both eyes in less than 10 minutes. Examining the local and cortical vision impulse can be powerfully diagnostic to differentiate optic nerve disorders and reduced vision of unknown etiology. Possibly most interesting is the clinically documented use of VEP measurements in the early diagnosis of glaucoma.²

VEP electrodiagnosis is billed with CPT code 95930. It is a bilateral code and many Medicare contractors and medical payers have a published payment policy for use of VEP, often bundled under a more general electrodiagnosis category.

Fluorescein Angiography
Many eye doctors consider fluorescein angiography not only old technology, but possibly dying technology, supplanted by the wonders of scanning lasers. While the necessary application of fluorescein angiography has certainly diminished, it still has significant diagnostic application and is considered by many retinal specialists to still be essential in the diagnosis of many chorioretinal disorders. Fluorescein angiography (92235) is reimbursed on a bilateral basis.

Optometrists should not overlook the value of oral fluorescein angiography, which is very easy to perform, much safer than intravenous fluorescein, and still highly diagnostic for many diseases showing mid- to late-phase leakage.

Scanning Lasers
Although scanning lasers are not new anymore, the scanning laser world was turned on its ear in January when the scanning laser CPT codes were reassigned. 92135 was discontinued and replaced with 92132 (anterior segment analysis), 92133 (optic nerve analysis) and 92134 (retina analysis). Providers should be very careful to understand the payment guidelines associated with these codes—or, more often, the lack of payment guidelines. At this time, most payers have not had time to formulate payment guidelines or have elected to not publish policy yet. Medical necessity is the governing principle in most areas. CMS does not have formal payment guidelines, but it has formulated edits associated with these codes:

CPT CODE	CANNOT BILL WITH	OVERRIDE WITH USE OF -59 MODIFIER
92132	92133, 92134 92020	YES NO
92133	92134 92250	NO YES, BUT…
92134	92133 92250	NO YES, BUT…

Remember that these restrictions apply only to billing multiple procedures on the same visit. The use of the -59 modifier is a subject of great debate. When -59 modifier requirements are met, billing an anterior segment and posterior segment procedure during the same visit is allowed. Although CMS has allowed the -59 modifier when billing optic nerve and retina lasers on the same visit, this practice is discouraged.

Inappropriate use of the -59 modifier has been cited as a significant problem in Medicare, and certainly gets the attention of auditors. CMS states that use of the -59 modifier is allowed when analyzing “different sites or organ systems or different lesions in the same organ.” But the Correct Coding Initiative guidelines on the -59 modifier go one step further to define the entire posterior segment of the eye as a single organ system, which would in and of itself preclude the use of this modifier.

Clinical Coding Committee

• John Rumpakis, O.D., M.B.A.,   Clinical Coding Editor • Joe DeLoach, O.D. • David Mills, O.D., M.B.A. • Laurie Sorrenson, O.D. • Rebecca Wartman, O.D.

The scrutiny and uncertainty of clear payment guidelines with the -59 modifier should make providers extremely cautious in its application and use with the scanning laser codes.

Please send your comments to CodingAbstract@gmail.com.

1. Weinreb RN, Harris A, eds. Section II: Clinical Measurement of Ocular Blood Flow. Kugler Publications; Amsterdam, The Netherlands: 2009. Ocular Blood Flow in Glaucoma: The 6th Consensus Report of the World Glaucoma Association: 59.
2. Hood DC, Thienprasiddhi P, Greenstein VC, et al. Detecting early to mild glaucomatous damage: a comparison of the multifocal VEP and automated perimetry. Invest Ophthalmol Vis Sci. 2004 Feb;45(2):492-8.