CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Defines coverage for scanning computerized ophthalmic diagnostic imaging (posterior segment OCT/SCODI) for Medicare Advantage and Commercial products, including clinical indications considered reasonable and necessary and coding guidance specifying CPT 92133 when paired with appropriate ICD-10 diagnoses.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Scanning Computerized Ophthalmic Diagnostic Imaging

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionWhen billing CPT 92133, providers must report one of the ICD-10 diagnosis codes listed in the policy attachment; the CPT code is medically necessary only when filed with an appropriate ICD-10 code.

SourceLink

POLICY UPDATE CHANGES

No material changes

1Primary CPT covered

MultipleApplicable ICD-10 diagnosis codes required (attachment)

Coverage Summary

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI / Posterior Segment OCT) coverage defines use of posterior segment optical coherence tomography for Medicare Advantage and Commercial products, specifying clinical indications considered reasonable and necessary and coding guidance requiring CPT 92133 when paired with appropriate ICD-10 diagnoses. Effective: 2022-01-01. Last review: 2023-03-15.

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Medical Necessity Criteria

Medically Necessary Indications for Posterior Segment SCODI / OCT

Posterior segment OCT is considered reasonable and necessary when used for the following clinical purposes:

ALL of the following

Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases involving changes in the nerve, subretinal and intraretinal changes, vitreo-retinal relationships, and nerve fiber layer
Differentiate causes of other nerve disorders when a diagnosis is in doubt
Diagnose early glaucoma and monitor glaucoma treatment
Diagnose and manage the patient's condition when visual field results are insufficient or reliable visual field testing cannot be performed due to visual, physical, mental, or age constraints
Differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields
Detect further loss of nerve or retinal nerve fiber changes in the presence of advanced nerve damage and advanced visual field loss
Follow glaucoma suspects

General Coding Condition

SCODI CPT code is considered medically necessary only when filed with an appropriate ICD-10 diagnosis from the plan's attachment; other indications are not medically necessary.

ALL of the following

CPT 92133 must be filed with one of the ICD-10 diagnosis codes listed in the policy attachment
Other indications not listed in the attachment are considered not medically necessary

Provider Actions / Billing Guidance

Documentation Required

Link CPT 92133 to appropriate ICD-10 diagnosis

When billing CPT 92133, providers must report one of the ICD-10 diagnosis codes listed in the policy attachment; the CPT code is medically necessary only when filed with an appropriate ICD-10 code.

92133
ICD-10 codes are listed in the policy attachment

Billing Rule

Global vs component billing

Follow correct coding guidelines regarding filing for the global service or professional/technical component when reporting CPT 92133.

92133
Follow correct coding guidelines for global vs professional/technical components

Background

SCODI (posterior segment OCT) is a non-invasive, non-contact imaging technique that produces high-resolution, cross-sectional tomographic images of ocular structures for evaluation of anterior and posterior segment disease. It permits earlier detection of retinal and retinal nerve fiber layer pathologic changes before visual field loss, aids in glaucoma diagnosis and monitoring, helps discriminate between patients with and without glaucoma across intraocular pressure presentations, enables assessment of retinal and choroidal thickening and macular thickness for retinal edema, and displays vitreo-retinal and vitreo-papillary relationships to assist in surgical planning and assessment.

SCODI: Scanning Computerized Ophthalmic Diagnostic Imaging — posterior segment optical coherence tomography imaging.

Name	Number	Type	Effective
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)	L34380	LCD
Local Coverage Article and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)	456537	NCD