Whether the rules work for us or against us, there is usually very little gray between the black and white of interpretation.

But it’s those gray, in-between situations that worry me the most.

I bring this up because of a very timely change in policy—and a new gray area. As you know, the use of OCT and fundus photography performed on the same date of service on the same eye has always been considered “mutually exclusive”—thus, not allowed—according to the National Correct Coding Initiative (NCCI). This is defined as “procedures that cannot reasonably be performed at the same anatomic site or same patient encounter.”1

Many (yours truly included) have questioned the logic of this particular pairing. I can understand the genesis of the rule, because when Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) came on the scene in 1999, many of the outputs from the various instruments were very similar to fundus photographs. Needless to say, there have been significant changes to today’s SCODI technology that now clearly differentiate it from a fundus image. But, the rules have lagged behind, so it has remained inappropriate to perform both on the same day of service on the same patient.

Until now…

The 2013 NCCI policy manual includes a change to this rule: “Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92135) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier -59 to CPT code 92250.”1

Not ‘Mutually Exclusive’?
Now, ignoring the fact that this 2013 rule still uses the CPT code 92135 for SCODI that was retired on January 1, 2011 (and replaced with 92133 and 92134), this is a significant change in policy.

But, whoa, not so fast! What I fear is that everyone will rush into doing these procedures together on the same date of service, just because of a change in the rule.

Let’s consider a couple areas that could be problematic.

Which diagnoses are allowed? The policy manual includes no national list of these “limited number of clinical conditions.” The closest thing that I can find is a list of diagnoses that are allowed in the state of Florida, where this policy has been in place for a few years. Most of the diagnoses allowed in Florida are related to retinal disease; however, glaucoma is not included.

Where does the -59 fit in? The definition of modifier -59 is very specific and should not be taken lightly, as it is an often misused (overused) modifier that can raise the scrutiny of insurers and the Office of the Inspector General.

Modifier -59 is defined: “Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.”1

Modifier -59 is generally used as a modifier of last resort, when no other modifier fits the situation at hand. This NCCI policy specifically states to use modifier -59, so at least a reference exists should a claim get called into question.

While insurance coverage policies and rule sets typically lag the development and adoption of technology in our practices, it’s nice when we actually see some progress.

But be careful not to rush into doing both OCT and fundus photography together on every single patient until the carriers flesh out their policies. I’d like to see a definitive list of diagnoses allowed and a specific reference to CPT code(s) 92134 and 92133, if both are eventually allowed. n

Please send your comments to CodingAbstract@gmail.com.

1. Centers for Medicare & Medicaid Services. National Correct Coding Initiative Policy Manual For Medicare Services. Baltimore, MD: CMS; Revised January 1, 2013: I-32; XI-11; I-23.