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CurrentAmbetter NevadaPolicy CP.VP.14

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Coverage Criteria

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Medical necessity indications, limitations, and coding guidance for Scanning Computerized Ophthalmic Diagnostic Imaging (anterior and posterior segment OCT) for members of Centene-affiliated health plans managed by Ambetter Nevada/Envolve Vision.

Policy Summary

PayerAmbetter Nevada

PolicyScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Coverage Criteria

Policy CodePolicy CP.VP.14

Change TypeAnnual review — no material changes

Effective DateN/A

Last ReviewNov 1, 2023

Next Review DateN/A

Key ActionWhen billing CPT 92133 or 92134 include a supporting ICD-10 diagnosis from the listed codes to document medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes referenced (92132, 92133, 92134)

2 indicationsNot medically necessary for

SD-OCT requiredSD-OCT required for CQ/HCQ monitoring

~120+Distinct ICD-10 groups for 92134

Coverage Criteria for SCODI (OCT)

Anterior SCODI (CPT 92132)

Covered when ONE of the following anterior segment indications is present:

Anterior SCODI indications: 1) Diagnosis of suspected glaucoma with one of: (a) an optic nerve or nerve fiber layer defect suggestive of glaucoma (enlarged cup-disc ratio, asymmetric cup-disc ratio, notching or narrowing of the neuroretinal rim, disc hemorrhage, or suspicious nerve fiber layer alteration); (b) a visual field abnormality consistent with glaucoma; or (c) an elevated intraocular pressure (IOP) > 21 mm Hg; 2) Glaucoma evaluation/monitoring for any of: primary open angle glaucoma; glaucoma associated with anatomical lens anomaly; glaucoma resulting from pigment dispersion, pseudoexfoliation, angle closure or narrowing, low-tension pathology; glaucoma secondary to drug use, hypersecretion, aqueous misdirection, trauma or inflammation; 3) Corneal ulcer of critical depth or at risk of perforation; 4) Corneal edema, degeneration, or transplant rejection/failure/infection; 5) Iris cyst, atrophy, degeneration, or neoplasm; 6) Iridoschisis, anterior/posterior synechiae, goniosynechiae, iridodialysis, plateau iris syndrome, or angle closure.

From policy anterior SCODI listing (CPT 92132)

Posterior optic nerve SCODI (CPT 92133)

Covered when ONE of the following posterior optic nerve indications is present:

Policy Summary

PayerAmbetter Nevada

PolicyScanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Coverage Criteria

Policy CodePolicy CP.VP.14

Change TypeAnnual review — no material changes

Effective DateN/A

Last ReviewNov 1, 2023

Next Review DateN/A

Key ActionWhen billing CPT 92133 or 92134 include a supporting ICD-10 diagnosis from the listed codes to document medical necessity.

SourceLink

On This Page

Posterior optic nerve SCODI indications: Malignant neoplasm of brain, cranial nerves, pituitary or pineal glands, or craniopharyngeal duct; orbital cellulitis, myositis, cyst, edema or hemorrhage; exophthalmos or displacement of the globe; orbital atrophy, deformity, enlargement, or exostosis; enophthalmos; glaucoma evaluation/monitoring (including primary open-angle and drug/trauma/inflammation-associated glaucoma and glaucoma related to anatomical lens anomaly, pigment dispersion, pseudoexfoliation, angle closure/narrowing, low-tension pathology, hypersecretion/aqueous misdirection); optic nerve evaluation for papilledema, coloboma, drusen, pseudopapilledema, Foster-Kennedy syndrome, optic nerve sheath hemorrhage, or hypoplasia; visual pathway or optic chiasm neoplasm, inflammatory or vascular disorders; visual field defects; ocular injury; diabetic eye disease; orbital infections and inflammatory conditions.

From policy posterior optic nerve listing (CPT 92133)

Posterior retinal SCODI (CPT 92134)

Covered when ONE of the following posterior retinal indications is present:

Posterior retinal SCODI indications: Choroidal neoplasm (benign or malignant); ocular histoplasmosis duboisii; diabetic retinopathy/diabetic eye disease; hypertensive retinopathy; orbital cellulitis, osteomyelitis, periostitis, tenonitis, granuloma, myositis, cyst, edema or hemorrhage; exophthalmos or enophthalmos; orbital atrophy, cyst, deformity, enlargement or exostosis; staphyloma or scleral ectasia; focal chorioretinal inflammation; macular and choroidal scarring, atrophy, degeneration, or drusen; choroidal rupture or detachment; degenerative myopia; retinal detachment, edema, ischemia, or hemorrhage; retinal pigment epithelium detachment; vascular occlusion (central/partial/branch retinal artery, central/tributary retinal vein), changes in vascular appearance, exudative retinopathy, retinal micro-aneurysms, retinal neovascularization, vasculitis, or telangiectasias; baseline and annual evaluation for patients using chloroquine (CQ) or hydroxychloroquine (HCQ) when systemic lupus erythematosus or rheumatoid arthritis is present (requires SD-OCT).

From policy posterior retinal listing (CPT 92134)

Not Medically Necessary

Not covered in the following situations:

Not medically necessary: Advanced glaucomatous damage; screening for glaucoma.

Explicit not medically necessary statements from policy

Coverage tied to listed ICD-10 diagnoses for CPT 92133

Covered when the requested CPT 92133 is performed for a listed ICD-10 medical indication

Primary requirement: CPT 92133 imaging of the posterior segment/optic nerve is indicated when the claim includes one of the specified ICD-10 diagnosis codes listed for 92133 in this policy.

Provider must document the diagnosis code on the claim or medical record.

Medical necessity requirement — diagnosis match

Covered when the billed SCODI procedure corresponds to a listed ICD-10 diagnosis in this section

Primary requirement: The ICD-10 diagnosis submitted on the claim must match one of the listed medical indications for the specific SCODI CPT code (e.g., 92133 for optic nerve or 92134 for retina).

Lists of qualifying ICD-10 codes for each CPT are enumerated in the policy.

Medical indications (diagnosis list)

Covered when associated with any of the following diabetes-related retinal diagnoses (ICD-10):

Diabetes-related retinal ICD-10: Presence of any listed ICD-10 code from the E09.*, E10.*, E11.*, or E13.* series specifying diabetic retinopathy and/or diabetic macular edema (with appropriate 4th/5th characters for severity and laterality) as the billed diagnosis when requesting CPT 92134.

Extensive enumerated diabetes-related ICD-10 codes are provided in the policy; use exact code matching per claim.

Medical Indications (ICD-10 list)

Covered when the submitted diagnosis for posterior segment/retina matches one of the listed ICD-10 codes.

ICD-10 match: CPT 92134 is supported when paired with any listed ICD-10 diagnosis in this section indicating posterior segment/retinal disease, retinal vascular disease, retinal detachment, macular disease, or relevant orbital conditions.

List-based coverage; clinical documentation must support the selected ICD-10 code.

Medical Indications (ICD-10) for CPT 92134

Covered when ALL of the following are met

Diagnosis requirement: CPT 92134 (SCODI, posterior segment/retina) is medically indicated when the patient’s diagnosis is one of the ICD-10 codes listed in this section for posterior segment/retina conditions and the diagnosis is documented on the claim and in the medical record.

Provider must document the matching diagnosis code on the claim and in the medical record.

ICD-10-based medical indications for CPT 92134

Covered when the following ICD-10 diagnoses are present and support medical necessity for CPT 92134 (posterior segment, retina):

ICD-10 indication list: Presence of any of the listed ICD-10 codes for posterior segment/retina conditions (examples include H44.411-H44.443 series for hypotony, H59.031-H59.033 for cystoid macular edema post-cataract, contusion codes S05.11x/S05.12x, congenital posterior segment codes Q14.8-Q14.9, systemic disease ranges M06.x and M32.x, observation/follow-up codes Z03.89 and Z09.2, and Z79.899 for long term drug therapy). Exact code-to-procedure mapping is provided in the policy lists (chunks 126-128).

Use the policy’s enumerated ICD-10 entries to confirm coverage for CPT 92134.

Screening for glaucoma and imaging for advanced glaucomatous damage are explicitly excluded from coverage for SCODI. Requests or claims for SCODI performed solely for screening for glaucoma or to image advanced glaucomatous damage do not meet medical necessity per the policy and may be denied.

The lists of accepted ICD-10 diagnoses shown in this excerpt define the medical indications recognized by the policy for the referenced SCODI CPT codes. Any diagnosis that is not included in the ICD-10 code lists displayed here is not presented as an accepted indication in this section; providers should refer to the full policy for the complete diagnosis list and coverage details.

When billing CPT 92133 or 92134, the claim must include a supporting ICD-10 diagnosis that appears in the policy’s listed medical-indication code sets. A submission of CPT 92133 or 92134 without a corresponding listed ICD-10 diagnosis in this section may not satisfy the policy’s medical indication requirements and may be subject to denial.

The policy provides specific ICD-10 codes as medical indications for CPT 92134 (posterior segment, retina). No additional diagnosis codes beyond those enumerated in this section are provided here as accepted indications; claims paired with diagnosis codes not listed in this section may be unsupported under this policy.

Document history notes: vitreous membranes, strands and degeneration were removed from the medical indications for posterior segment/retina SCODI (CPT 92134) during a prior update (removal recorded in 09/2022–10/2022).

Reiterating the policy position: SCODI is considered not medically necessary for imaging of advanced glaucomatous damage and for screening for glaucoma; such uses are excluded from coverage.

This excerpt does not list every possible posterior-segment/retina ICD-10 diagnosis. Absence of a listed ICD-10 posterior-segment/retina diagnosis in this section implies that CPT 92134 may not be supported by the code lists shown here; providers should confirm the patient diagnosis is one of the policy’s specified codes before billing.

CPT and ICD-10 Code Guidance

Covered CPT Codes (referenced)CPTCovered

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-10 codes supporting 92132 indications (partial list included in this chunk)ICD-10

D31.32	Benign neoplasm of left choroid.
H11.031	Double pterygium of right eye.
H11.032	Double pterygium of left eye.
H11.033	Double pterygium of eye, bilateral.
H11.041	Peripheral pterygium, stationary, right eye.
H11.042	Peripheral pterygium, stationary, left eye.
H11.043	Peripheral pterygium, stationary, bilateral.
H11.051	Peripheral pterygium, progressive, right eye.
H11.052	Peripheral pterygium, progressive, left eye.
H11.053	Peripheral pterygium, progressive, bilateral.

1–10 of 50

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Medical Indications for 92132 - SCODI, anterior segmentICD-10Covered

H21.221	Degeneration of ciliary body, right eye.
H21.222	Degeneration of ciliary body, left eye.
H21.223	Degeneration of ciliary body, bilateral.
H21.231	Degeneration of iris (pigmentary), right eye.
H21.232	Degeneration of iris (pigmentary), left eye.
H21.233	Degeneration of iris (pigmentary), bilateral.
H21.241	Degeneration of pupillary margin, right eye.
H21.242	Degeneration of pupillary margin, left eye.
H21.243	Degeneration of pupillary margin, bilateral.
H21.251	Iridoschisis, right eye.

1–10 of 58

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Medical Indications for 92133 - SCODI, posterior segment, optic nerveICD-10Covered

C71.8	Malignant neoplasm of overlapping sites of brain.
C72.0	Malignant neoplasm of spinal cord.
C72.1	Malignant neoplasm of cauda equine.
C72.21	Malignant neoplasm of right olfactory nerve.
C72.22	Malignant neoplasm of left olfactory nerve.
C72.31	Malignant neoplasm of right optic nerve.
C72.32	Malignant neoplasm of left optic nerve.
C72.41	Malignant neoplasm of right acoustic nerve.
C72.42	Malignant neoplasm of left acoustic nerve.
C75.1	Malignant neoplasm of pituitary gland.

1–10 of 32

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Covered CPT Codes (referenced)CPTCovered

92133

Scanning Computerized Ophthalmic Diagnostic Imaging; posterior segment, optic nerve

Covered ICD-10 codes for 92133 (posterior segment, optic nerve)ICD-10Covered

H40.61X2	Glaucoma secondary to drugs, right eye, moderate stage
H40.61X3	Glaucoma secondary to drugs, right eye, severe stage
H40.62X1	Glaucoma secondary to drugs, left eye, mild stage
H40.62X2	Glaucoma secondary to drugs, left eye, moderate stage
H40.63X1	Glaucoma secondary to drugs, bilateral, mild stage
H40.811	Glaucoma with increased episcleral venous pressure, right eye
H40.812	Glaucoma with increased episcleral venous pressure, left eye
H40.813	Glaucoma with increased episcleral venous pressure, bilateral
H44.411	Flat anterior chamber hypotony of right eye
H44.412	Flat anterior chamber hypotony of left eye

1–10 of 28

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Covered ICD-10 codes for 92134 (posterior segment, retina)ICD-10Covered

B39.5	Histoplasmosis duboisii
C69.31	Malignant neoplasm of right choroid
C69.32	Malignant neoplasm of left choroid
D31.31	Benign neoplasm of right choroid
E08.3211	Diabetes mellitus due to underlying condition with mild NPDR with macular edema, right eye
E08.3212	Diabetes mellitus due to underlying condition with mild NPDR with macular edema, left eye
E08.3213	Diabetes mellitus due to underlying condition with mild NPDR with macular edema, bilateral
E08.3291	Diabetes mellitus due to underlying condition with mild NPDR without macular edema, right eye

ICD-10 codes listed as medical indications for CPT 92134mixed

92134	SCODI, posterior segment, retina (procedure referenced throughout)
E09.3211	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E09.3212	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E09.3213	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3291	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E09.3292	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E09.3293	Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3311	Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

Referenced CPTCPT

92134

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), posterior segment/retina (procedure referenced as indication target)

Medical Indications / Covered ICD-10 Codes for CPT 92134ICD-10Covered

H33.031	Retinal detachment with multiple breaks, bilateral
H33.032	Retinal detachment with giant retinal tear, right eye
H33.033	Retinal detachment with giant retinal tear, left eye
H33.041	Retinal detachment with retinal dialysis, bilateral
H33.042	Retinal detachment with retinal dialysis, right eye
H33.043	Retinal detachment with retinal dialysis, left eye
H33.051	Total retinal detachment, right eye
H33.052	Total retinal detachment, left eye
H33.053	Total retinal detachment, bilateral
H33.111	Cyst of ora serrata right eye

1–10 of 21

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Covered ICD-10 and CPT codes for posterior segment, retina SCODImixedCovered

92134	SCODI, posterior segment, retina (CPT)
H44.411	Flat anterior chamber hypotony of right eye
H44.412	Flat anterior chamber hypotony of left eye
H44.413	Flat anterior chamber hypotony, bilateral
H44.421	Hypotony of right eye due to ocular fistula
H44.422	Hypotony of left eye due to ocular fistula
H44.423	Hypotony of bilateral eyes due to ocular fistula
H44.431	Hypotony of right eye due to other ocular disorders
H44.432	Hypotony of left eye due to other ocular disorders
H44.433	Hypotony of bilateral eyes due to other ocular disorders

1–10 of 29

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Elevated intraocular pressure — threshold (IOP)

Threshold> 21 mm Hg

Placeholder key value — thresholds

ThresholdNone specified in excerpt

Provider Billing, Documentation, and Prior Authorization Actions

Billing Rule

CPT code billing — use 92132, 92133, 92134

Bill SCODI procedures using the listed CPT codes: 92132 for anterior segment imaging, 92133 for posterior segment imaging focused on the optic nerve, and 92134 for posterior segment imaging focused on the retina; include interpretation and report per CPT descriptions when submitting claims.

92132 — Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report.
92133 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; optic nerve.
92134 — Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; retina.

Prior Authorization

Link CPT 92133 to listed ICD-10 indications

When performing or requesting coverage for CPT 92133 (posterior segment — optic nerve), pair the procedure with one of the ICD-10 diagnoses listed for 92133 (examples include C69.81/C69.82 for ocular neoplasms and numerous brain/cranial nerve neoplasm and orbital codes) to demonstrate the listed medical indications.

Accepted ICD-10 examples for 92133 include C69.81, C69.82, C71.x series, C72.x series, D33.3, D35.2–D35.4, D42.x–D44.x, and orbital codes H05.011–H05.013.
Claims for 92133 should include one of the listed ICD-10 codes to show the medical indication.

Billing Rule

Link CPT 92132 to anterior-segment ICD-10 codes

When billing CPT 92132 (anterior segment), include an ICD-10 diagnosis from the anterior-segment list (e.g., C69.*, D31.*, H11.*, H16.*, H18.*, H21.* ranges) that corresponds to the medical indication being evaluated or monitored.

Examples of supporting ICD-10s for 92132 include malignant and benign neoplasm codes (C69.*, D31.*), corneal/ocular surface codes (H11.*, H16.*), corneal dystrophy and ectasia (H18.*), and iris/angle codes (H21.*).
Ensure the claim diagnosis aligns with the documented anterior-segment indication.

Prior Authorization

Prior authorization / diagnosis requirement for CPT 92133

CPT 92133 is supported only when the claim and medical record show one of the ICD-10 medical indications listed for posterior segment/optic nerve imaging; prior authorization (where applicable) and coverage review should reference those diagnosis-code pairings.

Do not submit CPT 92133 without an associated listed ICD-10 diagnosis for the posterior segment/optic nerve.
Prior authorization requests (if required) should cite the specific ICD-10 code from the 92133 indication list.

Documentation Required

Diagnosis required on claim for 92133 and 92134

Include a supporting ICD-10 diagnosis from the listed codes when requesting coverage for CPT 92133 or CPT 92134; the submitted diagnosis must match one of the codes enumerated in the policy to demonstrate medical necessity.

For 92133, use a listed optic nerve/posterior-segment ICD-10 (see 92133 lists).
For 92134, use a listed posterior-segment/retina ICD-10 (see 92134 lists, including diabetes-related and retinal disorder codes).

Prior Authorization

Ensure 92134 is paired with a listed diabetes/retina ICD-10

When billing CPT 92134 (posterior segment — retina), ensure the submitted diagnosis code is one of the diabetes-related or other posterior-segment ICD-10 codes listed in the policy (E09.*, E10.*, E11.*, E13.* subcodes and many retinal-specific codes) to support medical necessity.

Commonly used supporting ICD-10s include E08–E13 subcodes specifying diabetic retinopathy/macular edema (e.g., E11.3211, E11.3311, etc.).
Claims for 92134 without a listed diabetes-related or listed posterior-retina ICD-10 diagnosis risk denial.

Prior Authorization

Pair CPT 92134 with an appropriate listed ICD-10 diagnosis

Pair CPT 92134 on claims with an appropriate listed posterior segment/retina ICD-10 code from the policy's enumerated lists; prior authorization (if applicable) and claim review reference these diagnosis-code pairings.

92134 should be billed only with an ICD-10 code listed under the 92134 medical indications (retina/posterior segment).
Prior authorization processes should use the documented ICD-10–CPT mappings in the policy.

Prior Authorization

Prior authorization: use policy-listed ICD-10 codes for 92134

Prior authorization and coverage for CPT 92134 rely on the presence of a listed ICD-10 posterior-segment/retina diagnosis; reference the policy's enumerated ICD-10 codes when submitting requests.

The policy provides specific ICD-10 codes (e.g., retinal detachment H33.*, hypotony H44.411–H44.443, cystoid macular edema H59.031–H59.033, and diabetes-related E09–E13 subcodes) that support 92134.
Include the exact ICD-10 code from the list in prior authorization documentation.

Documentation Required

Document 92134 with one of the policy's specified ICD-10 codes

Support CPT 92134 with one of the specific ICD-10 diagnoses listed in the policy (the document enumerates numerous posterior-segment/retina codes); clinical documentation and the claim must reference a matching listed code to establish medical necessity.

Examples include H44.411–H44.443 (hypotony series), H59.031–H59.033 (cystoid macular edema post-cataract), S05.11x/S05.12x contusion codes, Q14.8–Q14.9 congenital posterior segment codes, and systemic disease codes (M06.*, M32.*).
Annual review notes and history in the policy confirm use of these listed ICD-10 codes to support 92134 billing.

Step Therapy

Refer patients to SD-OCT–equipped centers when necessary

If your practice lacks SD-OCT capability, refer the patient to a facility or office that has SD-OCT available, particularly when SD-OCT is required (for example, baseline and annual HCQ/CQ monitoring).

SD-OCT is required for CQ/HCQ baseline and annual monitoring and is specified in the policy.
Referral to an SD-OCT–equipped site ensures adherence to the technology requirement.

Billing Rule

Coding and equipment guidance — include interpretation/report and matching ICD-10

Follow coding and equipment guidance: use CPT 92132, 92133, or 92134 with an interpretation and report and include the matching ICD-10 diagnosis that documents the medical indication; refer to policy ICD-10 lists and use SD‑OCT when required.

Submit the CPT code with an interpretation and report per the CPT descriptions in the policy.
Include the specific ICD-10 that matches the medical indication on the claim and in the medical record.
Use SD-OCT for CQ/HCQ monitoring as required by the policy.

Billing Rule

Include a matching ICD-10-CM when billing 92132

When billing anterior-segment SCODI (92132), include a matching ICD-10-CM diagnosis from the policy's anterior-segment list (for example retained foreign body, intraocular lens displacement/breakdown, device complications) that corresponds to the medical indication.

Examples: T85.21x/T85.22x for IOL breakdown/displacement, H44.611–H44.713 retained foreign body codes, and the malignant/benign neoplasm codes listed in the anterior-segment section.
Ensure the ICD-10 on the claim reflects the documented anterior-segment condition.

Documentation Required

Document matching ICD-10 diagnosis for 92133

Document an appropriate listed ICD-10 diagnosis as the medical indication when billing CPT 92133; medical record documentation must support the chosen ICD-10 from the policy's 92133 lists.

Clinical notes should record the diagnosis (e.g., orbital cellulitis H05.011–H05.013, neoplasm codes) that matches the ICD-10 used on the claim.
Lack of documentation tying the diagnosis to a listed ICD-10 for 92133 may prompt coverage review or denial.

Documentation Required

Document matching ICD-10 for retina imaging (92134)

When billing CPT 92134, document the medical diagnosis corresponding to one of the listed ICD-10 codes for posterior segment/retina in the medical record to support medical necessity and claims adjudication.

Document retinal disorders (H33.*, H34.*, H35.*), diabetic retinopathy codes (E08–E13 subcodes), hypotony codes (H44.411–H44.443), or other listed posterior-segment diagnoses as appropriate.
Ensure the ICD-10 on the claim matches the diagnosis documented in the chart.

Documentation Required

Support diagnosis coding for 92134 — use exact E09/E10/E11/E13 subcodes

Clinical documentation must support one of the listed ICD-10 diagnoses (for example E09.*, E10.*, E11.*, E13.* with appropriate 4th/5th characters indicating retinopathy/macular edema and laterality) when billing CPT 92134.

Use the exact subcode (including laterality and macular edema status) from the policy when documenting diabetic retinopathy indications.
Documentation should show the clinical rationale (e.g., DME, proliferative DR) corresponding to the selected ICD-10 code.

Documentation Required

Supportive diagnosis required for 92134

Clinical documentation must support one of the listed ICD-10 posterior-segment/retina diagnoses as the medical indication for CPT 92134; include that code on the claim to demonstrate eligibility.

Policy lists extensive ICD-10 codes for retina/posterior-segment conditions that qualify for 92134; the chart must document the chosen code's condition.
Failure to document a listed ICD-10 diagnosis may lead to claim denial.

Documentation Required

Supporting diagnosis documentation for CPT 92134

Documentation should support one of the listed posterior-segment/retina ICD-10 diagnoses when billing CPT 92134 — include the specific listed code (for example H44.411–H44.443, H59.031–H59.033, S05.x contusion series) in both the record and the claim.

Policy examples: H59.031–H59.033 for cystoid macular edema post-cataract; S05.11x/S05.12x contusion codes; Q14.8–Q14.9 congenital posterior segment codes.
Use the listed ICD-10 code ranges cited in the policy when completing documentation and claims.

Documentation Required

Required diagnosis coding examples for 92134

Use the listed ICD-10 codes (policy provides specific examples such as H44.411–H44.443 for hypotony and H59.031–H59.033 for cystoid macular edema post‑cataract) when billing CPT 92134; claims lacking one of these listed diagnoses may not meet medical necessity requirements.

Include the exact listed ICD-10 code from the policy on the claim (e.g., H44.411, H59.031) to support 92134.
Ranges for systemic conditions (M06.00–M06.9, M32.0–M32.9) are also listed and should be used where applicable.

Denial Risk

Not medically necessary: glaucoma screening and advanced glaucomatous damage

SCODI is considered not medically necessary for advanced glaucomatous damage and for screening for glaucoma; claims submitted for these indications may be denied.

Do not use SCODI (92132/92133/92134) for glaucoma screening or imaging of advanced glaucomatous damage per policy.
Claims with those indications are at risk for denial as not medically necessary.

Denial Risk

Denial risk: diagnosis must match listed indications

Claims for SCODI (e.g., CPT 92132) may be denied if the submitted ICD-10‑CM diagnosis is not among the medical indications listed in the policy; verify the diagnosis code matches the policy list before billing.

Ensure the ICD-10 on the claim corresponds to an enumerated indication for the specific CPT code billed.
A mismatch between the billed CPT and an unlisted diagnosis increases denial risk.

Denial Risk

Eligibility risk: ensure 92133 is accompanied by a listed ICD-10

Claims for CPT 92133 may be denied if the claim lacks an accepted ICD-10 medical indication from the listed codes; confirm the diagnosis on the claim is one of the policy's 92133 codes.

Absence of a listed 92133 ICD-10 diagnosis on the claim may trigger coverage denial.
Document the listed diagnosis in the medical record and on the claim to establish eligibility.

Denial Risk

Denial risk: missing listed ICD-10 for 92133/92134

Claims for CPT 92133 or 92134 without one of the listed ICD-10 diagnosis codes may be at risk for denial; verify that the diagnosis code used is included in the policy's enumerated lists before submission.

Both 92133 and 92134 require an associated listed ICD-10 diagnosis to support medical necessity.
Claims lacking a listed diagnosis-code pairing may be denied during adjudication.

Denial Risk

Diagnosis-coding mismatch risk for 92134 (diabetic retina)

Claims for 92134 that are not paired with an associated diabetes-related retinal ICD-10 diagnosis (when applicable) may be at risk because the policy enumerates diabetes-related ICD-10 codes as accepted indications for retinal SCODI.

Use the exact diabetes-related ICD-10 subcodes (E09–E13) with laterality and macular edema status as listed when the indication is diabetic retinopathy or DME.
Failure to use a listed diabetes-related code for diabetic retinal indications increases denial risk.

Denial Risk

Denial risk: 92134 submitted with unlisted diagnosis

Submitting CPT 92134 without an associated listed ICD-10 diagnosis for posterior segment/retina (from the policy's enumerated list) may trigger denial; confirm the claim diagnosis appears in the document's 92134 code lists.

Policy lists many qualifying retina/posterior-segment ICD-10 codes (H33.*, H34.*, H35.*, E08–E13 subcodes, etc.); use one of these on the claim.
Claims with unlisted diagnoses for 92134 are liable to be denied.

Denial Risk

Denial risk: 92134 requires a listed ICD-10 diagnosis

Claims for CPT 92134 may be denied if the submitted diagnosis is not one of the listed ICD-10 codes designated as medical indications for 92134 in the policy; verify exact code mapping prior to submission.

The policy explicitly ties 92134 coverage to the enumerated ICD-10 diagnosis codes for posterior segment/retina.
Use the specific listed ICD-10 code (including required 4th/5th characters) to avoid denial.

Denial Risk

Denial risk: mismatch between ICD-10 and listed indications for 92134

Claims may be denied if the ICD-10 diagnosis codes billed do not match the policy's listed medical indications for CPT 92134; ensure the diagnosis on the claim exactly matches one of the enumerated codes for posterior segment/retina.

Policy history and lists identify the specific codes that support 92134 (e.g., H44.411–H44.443, H59.031–H59.033, E09–E13 subcodes).
Accurate code selection and matching documentation reduce the risk of claim denial.

Background and Definitions

Optical coherence tomography (OCT/SCODI) is a noninvasive imaging technique that produces high-resolution cross-sectional images of the anterior and posterior ocular structures. SCODI (OCT) is used to evaluate corneal, iris, optic nerve, retinal and orbital conditions, and the policy specifies the use of spectral-domain OCT (SD-OCT) where higher resolution is required (for example, CQ/HCQ baseline and annual monitoring).

inv-67: Definition — SCODI (Scanning Computerized Ophthalmic Diagnostic Imaging)

TermSCODI = Scanning Computerized Ophthalmic Diagnostic Imaging

DefinitionA non-invasive, non-contact imaging technique that produces high-resolution, cross-sectional tomographic images of ocular structures for evaluation of anterior and posterior segment diseases.

ScopeIncludes anterior and posterior segment imaging and forms the basis of the policy's medical necessity indications.

inv-68: Definition — SD-OCT (Spectral-domain Optical Coherence Tomography) guidance for CQ/HCQ monitoring

TermSD-OCT (Spectral-domain Optical Coherence Tomography)

DefinitionOCT technology with sufficient resolution to detect early retinal changes from chloroquine (CQ) or hydroxychloroquine (HCQ); required for baseline and annual monitoring of CQ/HCQ users.

Provider actionProviders without SD-OCT should refer patients to centers with SD-OCT for CQ/HCQ monitoring.

inv-69: Definition — SCODI procedures referenced by CPT codes 92132 and 92133

ScopeSCODI procedures include imaging referenced by CPT codes 92132 (anterior segment) and 92133 (posterior segment/optic nerve)

NotesCPT 92133 is specifically described for posterior segment/optic nerve imaging in the policy's definitions and indications.

ImplicationWhen billing 92133, pair the procedure with one of the listed ICD-10 diagnoses in the posterior optic nerve section to support medical necessity.

inv-70: Definition — SCODI / CPT 92133 (posterior segment/optic nerve)

CPT mapping92133 — Scanning Computerized Ophthalmic Diagnostic Imaging; posterior segment, optic nerve

PurposeUsed for imaging and evaluation of posterior segment/optic nerve conditions as enumerated in the policy (e.g., optic nerve pathology, orbital disease, glaucoma-related optic nerve evaluation).

RequirementClaims for 92133 should include a supporting ICD-10 diagnosis from the listed posterior optic nerve indications to demonstrate medical necessity.

inv-71: Definition — 92133 / 92134 description

92133 vs 9213492133 — posterior segment, optic nerve; 92134 — posterior segment, retina (both are SCODI posterior procedures)

DescriptionsPolicy lists 92133 for optic nerve/posterior segment optic nerve conditions and 92134 for posterior retina indications including diabetic and other retinal diseases.

Billing guidanceWhen selecting 92133 or 92134, ensure the billed CPT matches the anatomic focus in documentation and the corresponding listed ICD-10 diagnosis.

inv-72: Definition — Diabetic retinopathy / diabetic macular edema (ICD-10 E09*, E10*, E11*, E13*)

ICD-10 groupsDiabetic retinopathy and diabetic macular edema grouped under E09*, E10*, E11*, E13* subcodes

DefinitionThese ICD-10 subcodes denote diabetic retinal disease (nonproliferative and proliferative) with specification for macular edema status and laterality used as medical indications for CPT 92134.

Provider noteWhen billing 92134 for diabetic retinal disease, include the precise E09/E10/E11/E13 subcode that specifies retinopathy/macular edema and laterality.

inv-73: Definition — 92134 - SCODI, posterior segment/retina

Term92134 — SCODI, posterior segment/retina

DefinitionSCODI procedure for imaging the posterior segment and retina; indicated for a broad list of retinal and orbital posterior-segment conditions enumerated in the policy.

DocumentationCPT 92134 claims must be paired with one of the listed posterior segment/retina ICD-10 diagnoses to support medical necessity.

inv-74: Definition — SCODI / 92134 (posterior segment/retina)

Term mappingSCODI billed with CPT 92134 — posterior segment/retina imaging

Clinical scopeUsed to evaluate retinal detachment, vascular occlusions, macular disease, age-related macular degeneration, and other posterior retinal disorders as listed.

RequirementDocumentation should support one of the listed ICD-10 posterior-segment/retina diagnoses when billing 92134.

inv-75: Definition — SCODI (general)

General termSCODI = Scanning Computerized Ophthalmic Diagnostic Imaging

SummaryNoninvasive high-resolution OCT-based imaging used to evaluate anterior and posterior ocular structures; policy defines medical necessity and cites clinical references.

EvidencePolicy references AAO and other clinical guidelines supporting OCT use in glaucoma and retinal disease assessment.