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Date Printed: December 18, 2017: 11:35 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92000-17

Original Effective Date: 04/17/00

Reviewed: 08/26/10

Revised: 10/01/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Scanning Computerized Ophthalmic Diagnostic Imaging

Clinical View

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This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION:

Scanning computerized diagnostic ophthalmic imaging (SCODI) includes scanning laser polarimetry, optical coherence tomography (OCT), and confocal scanning laser ophthalmoscopy. These testing devices use videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina. Several methods are described below:

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Scanning Computerized Ophthalmic Diagnostic Imaging - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Scanning computerized laser ophthalmic imaging, posterior segment, (CPT codes 92133, 92134) meets the definition of medical necessity when used:

Glaucomatous damage is based on the following criteria:

Mild glaucomatous damage or glaucoma suspect as demonstrated by one (1) of the following:

Moderate glaucomatous damage as demonstrated by one (1) of the following:

Scanning computerized laser ophthalmic imaging meets the definition of medical necessity for patients with advanced glaucomatous damage who demonstrate any of the following, only when visual field testing cannot initially be performed:

Scanning computerized laser ophthalmic imaging, posterior segment, is considered experimental or investigational when performed solely as a screening method, for confirmation of a known diagnosis of glaucoma, or other indications not listed, as there is insufficient clinical evidence to support the use of these tests for decision-making for those conditions.

Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral (CPT code 92132) is considered experimental or investigational as the available published clinical evidence does not support clinical value.

BILLING/CODING INFORMATION:

CPT Coding:

92132

Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (investigational)

92133

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

92134

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

B39.4

Histoplasmosis capsulate, unspecified

B73.01 – B73.09

Onchocerciasis with eye disease

C69.30 – C69.32

Malignant neoplasm of choroid

C71.0 – C71.9

Malignant neoplasm of brain

D18.09

Hemangioma of other sites

D31.30 – D31.32

Benign neoplasm of choroid

E08.311 – E08.39

Diabetes mellitus due to underlying condition with ophthalmic complications

E09.311 – E09.39

Drug or chemical induced diabetes mellitus with ophthalmic complications

E10.311 – E10.39

Type 1 diabetes mellitus with ophthalmic complications

E11.311 – E11.39

Type 2 diabetes mellitus with ophthalmic complications

E13.311 – E13.39

Other specified diabetes mellitus with ophthalmic complications

G45.3

Amaurosis fugax

H05.00 – H05.9

Disorders of the orbit

H15.041 – H15.043

Scleritis with corneal involvement

H15.811 – H15.859

Staphyloma; scleral ectasia

H21.231 – H21.239

Degeneration of iris (pigmentary)

H21.331 – H21.333

Parasitic cyst of iris, ciliary body or anterior chamber

H21.551 – H21.553

Recession of changer angle

H30.001 – H31.93

Chorioretinal inflammation

H31.001 – H31.8

Other disorders of choroid

H32

Chorioretinal disorders in diseases classified elsewhere

H33.001 – H33.8

Retinal detachment with retinal breaks

H34.00 – H34.9

Retinal vascular occlusions

H35.00 – H35.82

Other retinal disorders

H36

Retinal disorders in diseases classified elsewhere

H40.001 – H40.009

Preglaucoma

H40.011 – H40.019

Open angle glaucoma with borderline findings, low risk

H40.021 – H40.029

Open angle glaucoma with borderline findings, high risk

H40.031 – H40.039

Anatomical narrow angle glaucoma

H40.041 – H40.049

Steroid responder

H40.051 – H40.059

Ocular hypertension

H40.061 – H40.069

Primary angle closure without glaucoma damage

H40.10X0 – H40.10X4

Open angle glaucoma

H40.1110 – H40.1194

Primary open-angle glaucoma, staged

H40.1210 – H40.1294

Low-tension glaucoma

H40.1310 – H40.1394

Pigmentary glaucoma

H40.1410 – H40.1494

Capsular glaucoma with pseudoexfoliation of lens

H40.1510 – H40.1594

Residual stage of open-angle glaucoma

H40.20X0 – H40.20X4

Unspecified primary angle-closure glaucoma

H40.2110 – H40.2194

Acute angle-closure glaucoma, attack or crisis

H40.2210 – H40.2294

Chronic angle-closure glaucoma

H40.231 – H40.239

Intermittent angle-closure glaucoma

H40.241 – H40.249

Residual stage of angle-closure glaucoma

H40.30X0 – H40.33X4

Glaucoma secondary to eye trauma

H40.40X0 – H40.43X4

Glaucoma secondary to eye inflammation

H40.50X0 – H40.53X4

Glaucoma secondary to other eye disorders

H40.60X0 – H40.63X4

Glaucoma secondary to drugs

H40.811 – H40.9

Other and unspecified glaucoma

H42

Glaucoma in diseases classified elsewhere

H43.00 – H43.9

Disorders of vitreous body

H44.121 – H44.123

Parasitic endophthalmitis

H44.131 – H44.139

Sympathetic uveitis

H44.20 – H44.23

Degenerative myopia

H44.40 – H44.449

Hypotony of eye

H46.00 – H47.399

Disorders of optic nerve and visual pathways

H47.511 – H47.649

Disorders of other visual pathways and visual cortex

H53.40 – H53.489

Visual field defects

Q14.0 – Q14.9

Congenital malformations of posterior segment of eye

Q15.0

Congenital glaucoma

Q75.2

Hypertelorism

Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm

Z79.899

Other long term (current) drug therapy

LOINC Codes:

The following information may be required documentation to support medical necessity: physician consultation notes, physician progress notes, ophthalmology testing or studies and treatment plan.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Ophthalmology evaluation and management note

34808-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Ophthalmology consultation note

34807-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Ophthalmology/optometry studies (set)

28619-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Ophthalmology referral note

57150-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L29276) located at fcso.com.

DEFINITIONS:

Applanation: undue flatness, as of the cornea.

Arcuate: shaped like an arc.

Ciliary body: The structure in the eye that releases a transparent liquid (aqueous humor) inside the eye.

Cornea: The domed, transparent covering in the front of the eye that covers the iris and helps focus light on the retina.

Glaucoma: a group of eye diseases characterized by an increase in intraocular pressure which causes pathological changes in the optic disk and defects in the field of vision.

Intraocular: within the eye.

Iris: The colored disc inside of the eye which controls the size of the pupil.

Isopter: a line depicting the area in the field of vision in which the visual acuity is the same.

Scotoma: an area of lost or depressed vision within the visual field, surrounded by an area of less depressed or of normal vision.

RELATED GUIDELINES:

None applicable

OTHER:

None applicable

REFERENCES:

  1. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-6911. Diabetic Retinopathy. 05/15/09.
  2. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-6913. Idiopathic Macular Hole. 05/15/09.
  3. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-7151. Age-Related Macular Degeneration. 09/01/09.
  4. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma (Initial Evaluation). Summary of Benchmarks for Preferred Practice Pattern Guidelines. November 2008.
  5. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma (Follow-up Evaluation). Summary of Benchmarks for Preferred Practice Pattern Guidelines. November 2008.
  6. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation). Summary of Benchmarks for Preferred Practice Pattern Guidelines. November 2008.
  7. American Academy of Ophthalmology Ophthalmic Technology Assessment-Optic Nerve Head and Retinal Nerve Fiber Layer Analysis. Accessed 09/19/03.
  8. American Medical Association, CPT (current edition).
  9. Blue Cross Blue Association Medical Policy Reference Manual. 9.03.06 – Ophthalmologic Techniques of Evaluating Glaucoma. 11/12/09.
  10. Blue Cross Blue Shield Association Technology Assessment-Retinal Nerve Fiber Layer Analysis for the Diagnosis and Management of Glaucoma, Vol. 18, No. 17, 08/03.
  11. ECRI-Health Technology Assessment Information Service-Confocal Scanning Laser Ophthalmoscopy for the Diagnosis of Glaucoma, Issue No. 35, 07/00.
  12. Florida Medicare Part B Local Coverage Determination. Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L29276). 02/02/09 (revised 01/29/13).
  13. Greenfield et al. Role of Optic Nerve Imaging in Glaucoma Clinical Practice and Clinical Trials. Am J Ophthalmol. 2008 Apr; 145(4):598-603. Epub 2008 Mar 4.
  14. Halkaidakis et al. Comparison of Optical Coherence Tomography and Scanning Laser Polarimetry in Glaucoma, Ocular Hypertension, and Suspected Glaucoma. Ophthalmic Surg Laser Imaging. 2008 Mar-Apr: 39(2): 125-132.
  15. Hayes Directory of Technology of Assessments-Scanning Laser Polarimetry for Detection and Monitoring of Glaucoma, 06/02.
  16. Ortega et al. Discrimination between Glaucomatous and Nonglaucomatous Eyes Using Quantitative Imaging Devices and Subjective Optic Nerve Head Assessment. Invest Ophthalmol Vis Sci. 2006 Aug;47(8): 3374-80
  17. Ortega et al. Effect of Glaucomatous Damage on Repeatability of Confocal Scanning Laser Ophthalmoscope, Scanning Laser Polarimetry, and Optical Coherence Tomography. Invest Ophthalmol Vis Sci. 2007 Mar; 48(3): 1156-63.
  18. Shah et al. Combining Structural and Functional Testing for Detection of Glaucoma. Ophthalmology. 2006 Sep; 113(9): 1593-602.
  19. Vessani et al. Comparison of Quantitative Imaging Devices and Subjective Optic Nerve Head Assessment by General Ophthalmologists to Differentiate Normal From Glaucomatous Eyes. J Glaucoma. 2009 Mar;18(3): 253-61.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/26/10.

GUIDELINE UPDATE INFORMATION:

04/17/00

New MCG.

10/02/00

Various revisions.

12/31/00

Various revisions.

10/25/01

Reviewed investigational status – no changes.

08/15/02

Guidelines 01-92000-17 and 01-92000-19 combined. Optical Coherence Tomography added.

10/15/03

Annual review; reformatted description section, added additional ICD-9 diagnoses for Medicare & More that support medical necessity, deleted the reimbursement statement for code 92135 and codes (92081, 92082, and 92083), updated references. Added diagnoses 362.50 – 362.57 (Degeneration of macula and posterior pole).

10/16/03: Added statement for optical coherence tomography (OCT) for Medicare & More.

01/15/04

Deleted program exceptions for Medicare & More for 92135. Revised covered ICD-9 CM diagnoses for scanning computerized ophthalmic diagnostic imaging (92135) to be consistent with local Medicare B Medical Policy.

07/15/04

Guideline archived, no longer scheduled for review.

02/15/10

Guideline revised, reformatted and returned to active status. Description section updated, ICD 9 coding revised, and References updated.

09/15/10

Revision: MCG title changed; updated Billing/Coding Information section; updated Definitions section; added Program Exception for Medicare Advantage; revised Reimbursement Information section, and formatting changes.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Added codes 92132, 92133, and 92134; deleted codes 92135 and 0187T.

04/15/11

Revision; revised description and position statement sections for clarification; updated ICD-9 and ICD-10 coding sections; added formatting changes.

09/15/11

Revision; formatting changes.

10/01/11

Revision; added ICD9 codes 365.05, 365.06, 365.70, 365.71, 365.72 and 365.74.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

12/15/12

Revision; updated ICD10 coding.

02/15/13

Revision; added ICD9 codes 368.46, 368.47, V58.69 and V67.51; added ICD10 code Z09. Updated references.

08/15/13

Revision; added ICD9 codes 250.50, 250.51, 250.52, 250.53.

11/15/13

Revision; updated program exceptions section. Reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; updated ICD9 and ICD10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

08/15/16

Revision; updated ICD10 coding.

10/01/16

ICD-10 coding update: deleted codes H40.11X0-H40.11X4; added codes H40.1110 – H40.1194.

Date Printed: December 18, 2017: 11:35 AM