LCD/NCD Portal

L28982

 

SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (SCODI)

 

10-01-2011

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications of Coverage for Posterior Segment SCODI

• Posterior segment SCODI allows for early detection of glaucomatous damage to the nerve fiber layer or optic nerve of the eye.

o It is the goal of these diagnostic imaging tests to discriminate among patients with normal intraocular pressures (IOP) who have glaucoma, patients with elevated IOP who have glaucoma, and patients with elevated IOP who do not have glaucoma.

o These tests can also provide precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of follow-up exams than visual field and/or disc photos.

o This can allow earlier and more efficient efforts of treatment toward the disease process.

• Retinal disorders are the most common causes of severe and permanent vision loss.

o SCODI is also used for the evaluation and treatment of patients with retinal disease, especially certain macular abnormalities.

o It details the microscopic anatomy of the retina and the vitreo-retinal interface.

• FCSO Medicare will consider posterior segment SCODI medically reasonable and necessary under the following circumstances:

• 1. The patient presents with “mild” glaucomatous damage or “suspect glaucoma” as demonstrated by any of the following:

o Intraocular pressure ³ 22mmHg as measured by applanation.

o Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio > 0.4.

o Diffuse or focal narrowing or notching of disc rim, especially at inferior or superior poles.

o Diffuse or localized abnormalities of the retinal nerve fiber layer, especially at the inferior or superior poles.

o Nerve fiber layer disc hemorrhage.

o Asymmetrical appearance of the optic disc or rim between fellow eyes that suggests loss of neural tissue.

o Nasal step peripheral to 20 degrees or small paracentral or arcuate scotoma; or

o Mild constriction of visual field isopters.

• Because of the slow disease progression of patients with “suspect glaucoma” or those with “mild” glaucomatous damage, the use of scanning computerized ophthalmic diagnostic imaging at a frequency of > 1/year is not expected.

• 2. The patient presents with “moderate” glaucomatous damage as demonstrated by any of the following:

o Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio > 0.5 but < 0.8.

o Definite focal notch with thinning of the neural rim.

o Definite glaucomatous visual field defect (e.g., arcuate defect, nasal step, paracentral scotoma, or general depression).

• Patients with “moderate damage” may be followed with scanning computerized ophthalmic diagnostic imaging and/or visual fields.

o One or two tests of either per year may be appropriate.

o If both scanning computerized ophthalmic diagnostic imaging and visual field tests are used, only one of each test would be considered medically necessary, as these tests provide duplicative information.

• Scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary for patients with “advanced” glaucomatous damage. Instead, visual field testing should be performed.

o (Late in the course of glaucoma, when the nerve fiber layer has been extensively damaged, visual fields are more likely to detect small changes than scanning computerized ophthalmic diagnostic imaging).

• The patient with “advanced” glaucomatous damage would demonstrate any of the following:

o Diffuse enlargement of optic nerve cup, with cup to disc ratio > 0.8.

o Wipe-out of all or a portion of the neural retinal rim.

o Severe generalized constriction of isopters (i.e., Goldmann I4e ,< 10 degrees of fixation).

o Absolute visual field defects to within 10 degrees of fixation.

o Severe generalized reduction of retinal sensitivity.

o Loss of central visual acuity, with temporal island remaining.

• In addition, scanning computerized ophthalmic diagnostic imaging is not considered medically reasonable and necessary when performed to provide additional confirmatory information regarding a diagnosis which has already been determined.

 

Limitations of Coverage for Posterior Segment SCODI

• Performing Fundus Photography and SCODI on the Same Day on the Same Eye

• Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT code 92133 or 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease.

o 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 (National Correct Coding Initiative Policy Manual, Chapter 11, Section G, Ophthalmology).

• The physician is not precluded from performing fundus photography and posterior segment SCODI on the same eye on the same day under appropriate circumstances (i.e., when each service is necessary to evaluate and treat the patient.

• FCSO Medicare will consider fundus photography and posterior segment SCODI medically reasonable and necessary when performed on the same eye on the same day as outlined below.

• Fundus photography and Posterior Segment SCODI are frequently used together for the following diagnoses.

115.02

190.6

224.6

228.03

360.21

360.30-360.34

361.00-361.07

361.10-361.19

361.2

361.30-361.33

361.81

362.01

362.02

362.03

362.04

362.05

362.06

362.07

362.10-362.18

362.29

362.31

362.32

362.35

362.36

362.37

362.40-362.43

362.50-362.57

362.70-362.77

362.81

362.82

362.83

362.85

363.00-363.08

363.10-363.15

363.20-363.22

363.30-363.35

363.40-363.43

363.54

363.63

363.70-363.72

743.58

Indications of Coverage for Anterior Segment SCODI

• FCSO Medicare will consider anterior segment SCODI medically reasonable and necessary for evaluation of specified forms of glaucoma and disorders of the cornea, iris and ciliary body.

 

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

 

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0510 Clinic - General Classification

0920 Other Diagnostic Services - General Classification

 

 

CPT/HCPCS Codes

 

 

92132 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

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-9 Codes that Support Medical Necessity

 

 

ICD-9-CM codes applicable for CPT codes 92133 and 92134 (Do not report 92133 and 92134 at the same patient encounter)

115.02 HISTOPLASMA CAPSULATUM RETINITIS

190.6 MALIGNANT NEOPLASM OF CHOROID

191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE

224.6 BENIGN NEOPLASM OF CHOROID

228.03 HEMANGIOMA OF RETINA

360.11 SYMPATHETIC UVEITIS

360.21 PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA

360.30 HYPOTONY OF EYE UNSPECIFIED

360.31 PRIMARY HYPOTONY OF EYE

360.32 OCULAR FISTULA CAUSING HYPOTONY

360.33 HYPOTONY ASSOCIATED WITH OTHER OCULAR DISORDERS

360.34 FLAT ANTERIOR CHAMBER OF EYE

361.00 RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED

361.01 RECENT RETINAL DETACH PARTIAL WITH SINGLE DEFECT

361.02 RECENT RETINAL DETACH PARTIAL WITH MULTIPLE DEFECTS

361.03 RECENT RETINAL DETACH PARTIAL WITH GIANT TEAR

361.04 RECENT RETINAL DETACH PARTIAL WITH RETINAL DIALYSIS

361.05 RECENT RETINAL DETACH TOTAL OR SUBTOTAL

361.06 OLD RETINAL DETACH PARTIAL

361.07 OLD RETINAL DETACH TOTAL OR SUBTOTAL

361.10 RETINOSCHISIS UNSPECIFIED

361.11 FLAT RETINOSCHISIS

361.12 BULLOUS RETINOSCHISIS

361.13 PRIMARY RETINAL CYSTS

361.14 SECONDARY RETINAL CYSTS

361.19 OTHER RETINOSCHISIS AND RETINAL CYSTS

361.2 SEROUS RETINAL DETACH

361.30 RETINAL DEFECT UNSPECIFIED

361.31 ROUND HOLE OF RETINA WITHOUT DETACH

361.32 HORSESHOE TEAR OF RETINA WITHOUT DETACH

361.33 MULTIPLE DEFECTS OF RETINA WITHOUT DETACH

361.81 TRACTION DETACH OF RETINA

362.01 BACKGROUND DIABETIC RETINOPATHY

362.02 PROLIFERATIVE DIABETIC RETINOPATHY

362.03 NONPROLIFERATIVE DIABETIC RETINOPATHY NOS

362.04 MILD NONPROLIFERATIVE DIABETIC RETINOPATHY

362.05 MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.06 SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

362.07* DIABETIC MACULAR EDEMA

362.10 BACKGROUND RETINOPATHY UNSPECIFIED

362.11 HYPERTENSIVE RETINOPATHY

362.12 EXUDATIVE RETINOPATHY

362.13 CHANGES IN VASCULAR APPEARANCE OF RETINA

362.14 RETINAL MICROANEURYSMS NOS

362.15 RETINAL TELANGIECTASIA

362.16 RETINAL NEOVASCULARIZATION NOS

362.17 OTHER INTRARETINAL MICROVASCULAR ABNORMALITIES

362.18 RETINAL VASCULITIS

362.29 OTHER NONDIABETIC PROLIFERATIVE RETINOPATHY

362.31 CENTRAL RETINAL ARTERY OCCLUSION

362.32 RETINAL ARTERIAL BRANCH OCCLUSION

362.35 CENTRAL RETINAL VEIN OCCLUSION

362.36 VENOUS TRIBUTARY (BRANCH) OCCLUSION OF RETINA

362.37 VENOUS ENGORGEMENT OF RETINA

362.40 RETINAL LAYER SEPARATION UNSPECIFIED

362.41 CENTRAL SEROUS RETINOPATHY

362.42 SEROUS DETACH OF RETINAL PIGMENT EPITHELIUM

362.43 HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM

362.50 MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED

362.51 NONEXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.52 EXUDATIVE SENILE MACULAR DEGENERATION OF RETINA

362.53 CYSTOID MACULAR DEGENERATION OF RETINA

362.54 MACULAR CYST HOLE OR PSEUDOHOLE OF RETINA

362.55 TOXIC MACULOPATHY OF RETINA

362.56 MACULAR PUCKERING OF RETINA

362.57 DRUSEN (DEGENERATIVE) OF RETINA

362.70 HEREDITARY RETINAL DYSTROPHY UNSPECIFIED

362.71 RETINAL DYSTROPHY IN SYSTEMIC OR CEREBRORETINAL LIPIDOSES

362.72 RETINAL DYSTROPHY IN OTHER SYSTEMIC DISORDERS AND SYNDROMES

362.73 VITREORETINAL DYSTROPHIES

362.74 PIGMENTARY RETINAL DYSTROPHY

362.75 OTHER DYSTROPHIES PRIMARILY INVOLVING THE SENSORY RETINA

362.76 DYSTROPHIES PRIMARILY INVOLVING THE RETINAL PIGMENT EPITHELIUM

362.77 RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE

362.81 RETINAL HEMORRHAGE

362.82 RETINAL EXUDATES AND DEPOSITS

362.83 RETINAL EDEMA

362.85 RETINAL NERVE FIBER BUNDLE DEFECTS

363.00 FOCAL CHORIORETINITIS UNSPECIFIED

363.01 FOCAL CHOROIDITIS AND CHORIORETINITIS JUXTAPAPILLARY

363.03 FOCAL CHOROIDITIS AND CHORIORETINITIS OF OTHER POSTERIOR POLE

363.04 FOCAL CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.05 FOCAL RETINITIS AND RETINOCHOROIDITIS JUXTAPAPILLARY

363.06 FOCAL RETINITIS AND RETINOCHOROIDITIS MACULAR OR PARAMACULAR

363.07 FOCAL RETINITIS AND RETINOCHOROIDITIS OF OTHER POSTERIOR POLE

363.08 FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL

363.10 DISSEMINATED CHORIORETINITIS UNSPECIFIED

363.11 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS POSTERIOR POLE

363.12 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS PERIPHERAL

363.13 DISSEMINATED CHOROIDITIS AND CHORIORETINITIS GENERALIZED

363.14 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS METASTATIC

363.15 DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY

363.20 CHORIORETINITIS UNSPECIFIED

363.21 PARS PLANITIS

363.22 HARADA'S DISEASE

363.30 CHORIORETINAL SCAR UNSPECIFIED

363.31 SOLAR RETINOPATHY

363.32 OTHER MACULAR SCARS OF RETINA

363.33 OTHER SCARS OF POSTERIOR POLE OF RETINA

363.34 PERIPHERAL SCARS OF RETINA

363.35 DISSEMINATED SCARS OF RETINA

363.40 CHOROIDAL DEGENERATION UNSPECIFIED

363.41 SENILE ATROPHY OF CHOROID

363.42 DIFFUSE SECONDARY ATROPHY OF CHOROID

363.43 ANGIOID STREAKS OF CHOROID

363.54 CENTRAL CHOROIDAL ATROPHY TOTAL

363.63 CHOROIDAL RUPTURE

363.70 CHOROIDAL DETACH UNSPECIFIED

363.71 SEROUS CHOROIDAL DETACH

363.72 HEMORRHAGIC CHOROIDAL DETACH

364.22 GLAUCOMATOCYCLITIC CRISES

364.53 PIGMENTARY IRIS DEGENERATION

365.00 PREGLAUCOMA UNSPECIFIED

365.01 OPEN ANGLE WITH BORDERLINE FINDINGS, LOW RISK

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.03 STEROID RESPONDERS BORDERLINE GLAUCOMA

365.04 OCULAR HYPERTENSION

365.05 OPEN ANGLE WITH BORDERLINE FINDINGS, HIGH RISK

365.06 PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

365.10 OPEN-ANGLE GLAUCOMA UNSPECIFIED

365.11 PRIMARY OPEN ANGLE GLAUCOMA

365.12 LOW TENSION OPEN-ANGLE GLAUCOMA

365.13 PIGMENTARY OPEN-ANGLE GLAUCOMA

365.14 GLAUCOMA OF CHILDHOOD

365.15 RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA

365.22 ACUTE ANGLE-CLOSURE GLAUCOMA

365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA

365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA

365.31 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE

365.32 CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES

365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS

365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT ANOMALIES

365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 PHACOLYTIC GLAUCOMA

365.52 PSEUDOEXFOLIATION GLAUCOMA

365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER

365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK

365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS

365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE

365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS

365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA

365.81 HYPERSECRETION GLAUCOMA

365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE

365.83 AQUEOUS MISDIRECTION

365.89 OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA

368.40 VISUAL FIELD DEFECT UNSPECIFIED

368.41 SCOTOMA INVOLVING CENTRAL AREA

368.42 SCOTOMA OF BLIND SPOT AREA

368.43 SECTOR OR ARCUATE VISUAL FIELD DEFECTS

368.44 OTHER LOCALIZED VISUAL FIELD DEFECT

368.45 GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION

376.00 ACUTE INFLAMMATION OF ORBIT UNSPECIFIED

376.01 ORBITAL CELLULITIS

376.02 ORBITAL PERIOSTITIS

376.03 ORBITAL OSTEOMYELITIS

376.04 ORBITAL TENONITIS

376.10 CHRONIC INFLAMMATION OF ORBIT UNSPECIFIED

376.11 ORBITAL GRANULOMA

376.12 ORBITAL MYOSITIS

376.13 PARASITIC INFESTATION OF ORBIT

376.21 THYROTOXIC EXOPHTHALMOS

376.22 EXOPHTHALMIC OPHTHALMOPLEGIA

376.30 EXOPHTHALMOS UNSPECIFIED

376.31 CONSTANT EXOPHTHALMOS

376.32 ORBITAL HEMORRHAGE

376.33 ORBITAL EDEMA OR CONGESTION

376.34 INTERMITTENT EXOPHTHALMOS

376.35 PULSATING EXOPHTHALMOS

376.36 LATERAL DISPLACEMENT OF GLOBE

376.40 DEFORMITY OF ORBIT UNSPECIFIED

376.41 HYPERTELORISM OF ORBIT

376.42 EXOSTOSIS OF ORBIT

376.43 LOCAL DEFORMITIES OF ORBIT DUE TO BONE DISEASE

376.44 ORBITAL DEFORMITIES ASSOCIATED WITH CRANIOFACIAL DEFORMITIES

376.45 ATROPHY OF ORBIT

376.46 ENLARGEMENT OF ORBIT

376.47 DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY

376.50 ENOPHTHALMOS UNSPECIFIED AS TO CAUSE

376.51 ENOPHTHALMOS DUE TO ATROPHY OF ORBITAL TISSUE

376.52 ENOPHTHALMOS DUE TO TRAUMA OR SURGERY

376.6 RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT

376.81 ORBITAL CYSTS

376.82 MYOPATHY OF EXTRAOCULAR MUSCLES

376.89 OTHER ORBITAL DISORDERS

376.9 UNSPECIFIED DISORDER OF ORBIT

377.00 PAPILLEDEMA UNSPECIFIED

377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE

377.02 PAPILLEDEMA ASSOCIATED WITH DECREASED OCULAR PRESSURE

377.03 PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER

377.04 FOSTER-KENNEDY SYNDROME

377.10 OPTIC ATROPHY UNSPECIFIED

377.11 PRIMARY OPTIC ATROPHY

377.12 POSTINFLAMMATORY OPTIC ATROPHY

377.13 OPTIC ATROPHY ASSOCIATED WITH RETINAL DYSTROPHIES

377.14 GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC

377.15 PARTIAL OPTIC ATROPHY

377.16 HEREDITARY OPTIC ATROPHY

377.21 DRUSEN OF OPTIC DISC

377.22 CRATER-LIKE HOLES OF OPTIC DISC

377.23 COLOBOMA OF OPTIC DISC

377.24 PSEUDOPAPILLEDEMA

377.30 OPTIC NEURITIS UNSPECIFIED

377.31 OPTIC PAPILLITIS

377.39 OTHER OPTIC NEURITIS

377.41 ISCHEMIC OPTIC NEUROPATHY

377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS

377.43 OPTIC NERVE HYPOPLASIA

377.49 OTHER DISORDERS OF OPTIC NERVE

379.11 SCLERAL ECTASIA

379.12 STAPHYLOMA POSTICUM

379.13 EQUATORIAL STAPHYLOMA

379.14 ANTERIOR STAPHYLOMA LOCALIZED

379.15 RING STAPHYLOMA

379.16 OTHER DEGENERATIVE DISORDERS OF SCLERA

379.19 OTHER SCLERAL DISORDERS

379.21 VITREOUS DEGENERATION

379.22 CRYSTALLINE DEPOSITS IN VITREOUS

379.23 VITREOUS HEMORRHAGE

379.24 OTHER VITREOUS OPACITIES

379.25 VITREOUS MEMBRANES AND STRANDS

379.26 VITREOUS PROLAPSE

379.27 VITREOMACULAR ADHESION

379.29 OTHER DISORDERS OF VITREOUS

743.20 BUPHTHALMOS UNSPECIFIED

743.21 SIMPLE BUPHTHALMOS

743.22 BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES

743.57 SPECIFIED CONGENITAL ANOMALIES OF OPTIC DISC

743.58 VASCULAR ANOMALIES CONGENITAL

743.59 OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT

921.3 CONTUSION OF EYEBALL

 

ICD-9-CM codes applicable for CPT code 92132:

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.4 MALIGNANT NEOPLASM OF CORNEA

224.0 BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

224.4 BENIGN NEOPLASM OF CORNEA

364.51 ESSENTIAL OR PROGRESSIVE IRIS ATROPHY

364.52 IRIDOSCHISIS

364.53 PIGMENTARY IRIS DEGENERATION

364.54 DEGENERATION OF PUPILLARY MARGIN

364.55 MIOTIC CYSTS OF PUPILLARY MARGIN

364.56 DEGENERATIVE CHANGES OF CHAMBER ANGLE

364.57 DEGENERATIVE CHANGES OF CILIARY BODY

364.59 OTHER IRIS ATROPHY

364.60 IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY

364.61 IMPLANTATION CYSTS OF IRIS AND CILIARY BODY

364.62 EXUDATIVE CYSTS OF IRIS OR ANTERIOR CHAMBER

364.63 PRIMARY CYST OF PARS PLANA

364.64 EXUDATIVE CYST OF PARS PLANA

364.70 ADHESIONS OF IRIS UNSPECIFIED

364.71 POSTERIOR SYNECHIAE OF IRIS

364.72 ANTERIOR SYNECHIAE OF IRIS

364.73 GONIOSYNECHIAE

364.74 ADHESIONS AND DISRUPTIONS OF PUPILLARY MEMBRANES

364.75 PUPILLARY ABNORMALITIES

364.76 IRIDODIALYSIS

364.77 RECESSION OF CHAMBER ANGLE OF EYE

364.81 FLOPPY IRIS SYNDROME

364.82 PLATEAU IRIS SYNDROME

364.89 OTHER DISORDERS OF IRIS AND CILIARY BODY

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.06 PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA

365.22 ACUTE ANGLE-CLOSURE GLAUCOMA

365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA

365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA

365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES

365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS

365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT ANOMALIES

365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 PHACOLYTIC GLAUCOMA

365.52 PSEUDOEXFOLIATION GLAUCOMA

365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER

365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK

365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS

365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE

365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS

365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA

365.81 HYPERSECRETION GLAUCOMA

365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE

365.83 AQUEOUS MISDIRECTION

365.89 OTHER SPECIFIED GLAUCOMA

370.04 HYPOPYON ULCER

370.05 MYCOTIC CORNEAL ULCER

370.06 PERFORATED CORNEAL ULCER

371.03 CENTRAL OPACITY OF CORNEA

371.71 CORNEAL ECTASIA

371.72 DESCEMETOCELE

371.73 CORNEAL STAPHYLOMA

379.31 APHAKIA

379.32 SUBLUXATION OF LENS

379.33 ANTERIOR DISLOCATION OF LENS

379.39 OTHER DISORDERS OF LENS

996.51 MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT

996.53 MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS

996.69 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT

* ICD-9-CM code 362.07 (Diabetic macular edema) requires a dual diagnosis. 362.07 must be used with an ICD-9-CM code for diabetic retinopathy (ICD-9-CM codes 362.01-362.06).

 

 

Documentation Requirements

 

• Medical record documentation (e.g., office/progress notes) maintained by the performing physician must indicate the medical necessity of the scanning computerized ophthalmic diagnostic imaging

and be available to Medicare upon request.

• A copy of the test results, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams is required.

• Medical record documentation must clearly indicate rationale which supports the medical necessity for performing the fundus photography and posterior segment SCODI on the same day on the same eye.

• Documentation should also reflect how the test results were used in the patient’s plan of care.

• It would not be considered medically reasonable and necessary to perform fundus photography and posterior segment SCODI on the same day on the same eye to provide additional confirmatory information for a diagnosis or treatment which has already been determined.

Treatment Logic

• Many forms of scanning computerized ophthalmic diagnostic imaging (SCODI) tests currently exist (e.g., confocal laser scanning ophthalmoscopy (topography), scanning laser polarimetry, optical coherence tomography (OCT), and retinal thickness analysis).

o Although these techniques are different, their objective is the same.

• Confocal scanning laser ophthalmoscopy (topography) uses multiple tomographic images to make quantitative topographic measurements of either the optic nerve head or posterior retinal structures to detect glaucomatous damage to the nerve fiber layer of the retina or non-glaucomatous retinal changes in the microstructure of the posterior retina (e.g. macular edema, atrophy associated with degenerative retinal diseases).

• Scanning laser polarimetry measures change in the linear polarization of light (retardation).

o It uses a polarimeter, an optical device to measure linear polarization change and a scanning laser ophthalmoscope together to measure the thickness of the nerve fiber layer of the retina.

• Optical coherence tomography is a non-invasive, non-contact imaging technique.

o It produces high-resolution, longitudinal, cross-sectional tomographs of ocular structures to detect evidence of glaucomatous damage or subsurface retinal defects.

• Retinal thickness analysis is a computerized slit lamp biomicroscope that is intended to provide manual and computerized tomography of the retina in vivo to determine the thickness and the inner structure of the retina.

o It is indicated for assessing the area and location of retinal thickness abnormalities, such as thickening due to macular edema and atrophy associated with degenerative diseases, and for visualizing other retinal pathologies.

 

Sources of Information and Basis for Decision

 

Antcliff, R., Stanford, M., Chauhan, D., Graham, E., Spalton, D., Shilling, J, Ffytche, T. Marshall, J. (2000). Comparison between optical coherence tomography and fundus fluorescein angiography for the detection of cystoid macular edema in patients with uveitis. Ophthalmology, 107, 593-599.

 

Antcliff, R., Spalton, D., Stanford, M., Graham, E., Ffytche, T., Marshall, J. (2001). Intravitreal triamcinolone for uveitic cystoid macular edema: An optical coherence tomography study. Ophthalmology, 108(4), 765-772.

 

Azzolini, C., Patelli, F., Codenotti, M., Pierro, L., Brancato, R. (1999). Optical coherence tomography in idiopathic epiretinal macular membrane surgery. Eur J Ophthalmol, 9, 206-211.

 

Bakri, S., Singh, A., Lowder, C., Chalita, M., Li, Y., Izatt, J., Rollins, A., & Huang, D. (2007). Imaging of iris lesions with high-speed optical coherence tomography. Ophthalmic Surg Lasers Imaging, 38, 27-34.

 

Blumenthal, E., Williams, J., Weinreb, R., Girkin, C., Berr, C., Zangwill, L. (2000). Reproducibility of nerve fiber layer thickness measurements by use of optical coherence tomography. Ophthalmology, 107(12), 2278-2282.

 

FCSO LCD 29276, Scanning Computerized Ophthalmic Diagnostic Imaging, 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/

 

Fujii, G., De Juan, E., Bressler, N. (2001). Vitrectomy surgery for impending macular hole based on optical coherence tomography.Retina, 21(4), 389-392.

 

Gallemore, R., Jumper, M., McCuen, B., Jaffe, G., Postel, E., Toth, C. (2000). Diagnosis of vitreoretinal adhesions in macular disease with optical coherence tomography. Retina, 20(2), 115-120.

 

Garcia, J., Cruz, J., Rosen, R., & Buxton, D. (2008). Imaging implanted keratoprostheses with anterior-segment optical coherence tomography and ultrasound biomicroscopy. Cornea, 27, 180-188.

 

Garcia, J., Garcia, P., Buxton, D., Panarelli, A., & Rosen, R. (2007). Imaging through opaque corneas using anterior segment optical coherence tomography. Ophthalmic Surg Lasers Imaging, 38(4), 314-318.

 

Giovannini, A., Amato, G., Mariotti, C., Scassellati-Sforzolini, B. (2000). Optical coherence tomography in the assessment of retinal pigment epithelial tear. Retina, 20, 37-40.

 

Goebel, W., Kretzchmar-Gross, T. (2002). Retinal thickness in diabetic retinopathy-A study using optical coherence tomography (OCT). Retina, 22, 759-767.

 

Haouchine, B., Massin, P., Gaudric, A. (2001). Foveal pseudocyst as the first step in macular hole formation-A prospective study by optical coherence tomography. Ophthalmology, 108, 15-22.

 

Ito, Y., Terasaki, H., Mori, M., Kojima, T., Suzuki, T., Miyake, Y. (2000). Three-dimensional optical coherence tomography of vitreomacular traction syndrome before and after vitrectomy. Retina, 20(4), 403-405.

 

Kim, H., Budenz, D., Lee, P., Feuer, W., & Barton, K. (2008). Comparison of central corneal thickness using anterior segment optical coherence tomography vs. ultrasound pachymetry. Am J Ophthalmol, 145(2). Retrieved June 24, 2008 from MD Consult database (98160416-3).

 

Lai, M., Tang, M., Andrade, E., Li, Y., Khurana, R., Song, J., & Huang, D. (2006). Optical coherence tomography to assess intrastromal corneal ring segment depth in keratoconic eyes. J Cataract Refract Surg, 32, 1860-1865.

 

Lee, R., & Ahmed, I. (2006). Anterior segment optical coherence tomography: Non-contact high resolution imaging of the anterior chamber. Techniques in Ophthalmology, 4(3), 120-127.

 

Memarzadeh, F., Li, Y., Chopra, V., Varma, R., Francis, B., & Huang, D. (2007). Anterior segment optical coherence tomography for imaging the anterior chamber after laser peripheral iridotomy. Am J Ophthalmol, 143(5), 877-879.

 

Memarzadeh, F., Li, Y., Francis, B., Smith, R., Gutmark, J., & Huang, D. (2007). Optical coherence tomography of the anterior segment in secondary glaucoma with corneal opacity after penetrating keratoplasty. Br J Ophthalmol, 91, 189-192.

 

Memarzadeh, F., Tang, M., Li, Y., Chopra, V., Francis, B., & Huang, D. (2007). Optical coherence tomography assessment of angle anatomy changes after cataract surgery. Am J Ophthalmol, 144(3), 464-465.

 

Pons, M., Ishikawa, H., Gurses-Ozden, R., Liebmann, J., Dou, H., Ritch, R. (2000). Assessment of retinal nerve fiber layer internal reflectivity in eyes with and without glaucoma using optical coherence tomography. Arch Ophthalmol, 118, 1044-1047.

 

Radhakrishnan, S., Goldsmith, J., Huang, D., Westphal, V., Dueker, D., Rollins, A., Izatt, J., & Smith, S. (2005). Comparison of optical coherence tomography and ultrasound biomicroscopy for detection of narrow anterior chamber angles. Arch Ophthalmol, 123, 1053-1059.

 

Ripandelli, G., Coppe, A., Bonini, S., Giannini, R., Curci, S., Costi, E., Stirpe, M. (1999). Morphological evaluation of full-thickness idiopathic macular holes by optical coherence tomography. Eur J Ophthalmol, 9, 212-216.

 

Shields, M.B. (Ed.). (1998). Textbook of Glaucoma (4th ed.). Baltimore: Williams and Wilkins.

 

Smith, S. (July 2007). Anterior segment OCT and angle closure. Review of Ophthalmology, 80-82.

 

Tadayoni, R., Massin, P., Haouchine, B., Cohen, D., Erginay, A., Gaudric, A. (2001). Spontaneous resolution of small stage 3 and 4 full-thickness macular holes viewed by optical coherence tomography. Retina, 21(2), 186-189.

 

Tanner, V., Williamson, T. (2000). Watzke-Allen slit beam test in macular holes confirmed by optical coherence tomography. Arch Ophthalmol, 118, 1059-1063.

 

Ting, T., Oh, M., Cox. T., Meyer, C., Toth, C. (2002). Decreased visual acuity associated with cystoid macular edema in neovascular age-related macular degeneration. Arch Ophthalmol, 120, 731-737.

 

Uchino, E., Uemura, A, Ohba, N. (2001). Initial stages of posterior vitreous detachment in healthy eyes of older persons evaluated by optical coherence tomography. Arch Ophthalmol, 119, 1475-1479.

 

Wolffsohn, J., & Davies, L. (2007). Advances in ocular imaging. Expert Rev Ophthalmol, 2(5), 755-767.

 

Yanoff, M. (Ed.). (1998). Ophthalmic Diagnosis and Treatment. Philadelphia: Current Medicine, Inc.

 

 

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CMS LCD L28982 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)