Document medical indication for billed SCODI CPT

Coverage for SCODI CPT codes requires a documented medical indication consistent with the policy criteria for the specific SCODI CPT code (92132 — anterior segment; 92133 — posterior/optic nerve; 92134 — posterior/retina; 92137 — posterior/retina including OCT angiography).

Include supported ICD-10-CM diagnosis on claim

When billing CPT 92132 or 92133 include an ICD-10-CM diagnosis from the listed indications in the policy to support medical necessity for the anterior segment (92132) or optic nerve/orbit (92133) procedures.

Obtain prior authorization for CPT 92133 when required

If the payer requires prior authorization for CPT 92133, obtain authorization and ensure the request includes one of the acceptable ICD-10-CM medical indications listed for optic nerve/orbit imaging.

Submit appropriate ICD-10 diagnosis with CPT

Submit CPT 92133 and CPT 92134/92137 with one of the listed ICD-10-CM diagnosis codes that correspond to the anatomic/clinical indication for the procedure to justify medical necessity.

Link retina SCODI (92134/92137) to listed ICD-10 indications

Use of retina SCODI codes 92134 and 92137 must be associated with one of the listed ICD-10 diagnoses in the retina section; the excerpt does not specify a separate prior authorization process for these codes but links coverage to the enumerated diagnoses.

Ensure matching diagnosis for prior authorization of retina SCODI

Retina SCODI (CPT 92134, 92137) requests may require prior authorization/medical necessity review and must include an appropriate matching ICD-10 diagnosis from the list in the retina section.

Ensure appropriate ICD-10 when requesting authorization for 92134/92137

When seeking coverage or authorization for CPT 92134 or 92137, ensure the claim/request contains an appropriate ICD-10 indication from the policy’s retina diagnosis list to support medical necessity.

Link CPT to listed ICD-10 indications for authorization/coverage

Claims for SCODI CPTs 92132, 92133, 92134, and 92137 must be linked to one of the enumerated ICD-10 indications in this policy; providers should document and submit the supporting diagnosis when requesting authorization or submitting claims.

Use SD‑OCT for CQ/HCQ baseline and annual monitoring; refer if unavailable

Spectral-domain OCT (SD-OCT) is required for baseline and annual monitoring of patients on chloroquine (CQ) or hydroxychloroquine (HCQ); providers without SD-OCT should refer beneficiaries to offices or centers that have SD-OCT available.

• Baseline and annual CQ/HCQ evaluation requires SD-OCT per policy (chunk 5).
• Refer patients to facilities with SD-OCT if unavailable in-office (chunk 8).

Include CPT-based interpretation and report documentation

Reference current CPT guidance when coding SCODI services and include the interpretation and report documentation with claims to support the billed procedure.

Document the specific listed ICD-10-CM diagnosis in the medical record

Medical records must document one of the ICD-10-CM diagnoses enumerated in the policy that corresponds to the SCODI procedure billed (e.g., the anterior segment codes for 92132 or optic nerve codes for 92133).

Support CPT 92133 with clinical documentation of listed optic nerve diagnoses

Clinical documentation should support one of the listed ICD-10-CM optic nerve/orbit diagnoses as the medical indication when reporting CPT 92133.

Ensure medical record links diagnosis to the specific SCODI CPT

The medical record must support an ICD-10 diagnosis paired to the specific CPT SCODI code billed (optic nerve diagnoses for 92133; retina or diabetic retinopathy/vascular diagnoses for 92134/92137).

Document support for listed retina ICD-10 diagnoses when billing 92134/92137

Provider documentation should support one of the listed ICD-10 retina diagnoses (examples include E09*, E10*, E11*, E13*, G45.3, H05.*) when billing CPT 92134 or 92137.

Submit exact listed ICD-10 code that matches the ocular condition

Submit the specific ICD-10 diagnosis code from the policy’s list that corresponds to the patient’s ocular condition (examples include proliferative diabetic retinopathy and retinal vascular occlusion codes) on the claim.

Link SCODI retina service to an enumerated ICD-10 diagnosis

Documentation must explicitly link the SCODI service (CPT 92134 or 92137) to one of the enumerated ICD-10 retina diagnoses (e.g., H34.*, H35.*, H36.*, H43.*, H44.*, H53.*) included in the retina section.

Document ICD-10 medical indication and note coverage is subject to plan/state rules

Providers must document the medical indication (specific ICD-10 diagnosis) supporting the billed SCODI CPT code; coverage decisions remain subject to the member’s coverage terms, exclusions, and state Medicaid provisions.

Avoid billing SCODI for advanced glaucoma damage or glaucoma screening

SCODI is not medically necessary for advanced glaucomatous damage or for screening for glaucoma; use of SCODI for these indications may lead to claim denial.

Risk of denial if diagnosis does not match listed indications

Claims for CPT 92132 or 92133 may be denied if the submitted diagnosis code does not match one of the listed medical indications for those procedures.

Denial risk: 92133 billed without listed optic nerve diagnoses

Billing CPT 92133 without one of the listed ICD-10-CM diagnosis codes for optic nerve/orbit indications may trigger denial when the payer expects a matching medical indication.

92133 claims may be denied if no appropriate optic nerve diagnosis is provided

Claims for CPT 92133 may be denied if submitted without an appropriate listed ICD-10-CM diagnosis indicating an optic nerve or visual pathway disorder (examples shown in the policy).

Denial risk: 92134/92137 without listed retina diagnoses

Claims for CPT 92134 or 92137 may be denied if submitted without an appropriate listed ICD-10-CM retina diagnosis (examples include neoplasm codes and diabetic retinopathy codes).

Require listed ICD-10 diagnosis to support 92134/92137

Claims for CPT 92134 and 92137 require an appropriate supporting ICD-10 diagnosis from the policy’s listed medical indications; absence of an applicable diagnosis may trigger denial.

Support retina SCODI claims with a listed ICD-10 diagnosis

SCODI retina imaging claims must be supported by an appropriate ICD-10 diagnosis from the policy’s listed medical indications to be considered for coverage.

Denial risk if diagnosis code is not one of the listed retina ICD-10 codes

Claims for CPT 92134 or 92137 may be denied if the submitted diagnosis code is not one of the listed retina-related ICD-10 codes that support medical indication for the service.

Coverage subject to plan terms and state Medicaid provisions

Claims are subject to the Health Plan’s coverage provisions, exclusions and limitations; state Medicaid provisions take precedence where applicable and can affect coverage determinations.