CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI/OCT) — Posterior Segment

Policy governing medical coverage of posterior segment scanning computerized ophthalmic diagnostic imaging (eg, OCT) for Medicare Advantage and commercial products offered by Blue Cross Blue Shield - Rhode Island, including clinical indications and coding guidance for optic nerve imaging.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyScanning Computerized Ophthalmic Diagnostic Imaging (SCODI/OCT) — Posterior Segment

Policy CodePolicy N/A

Change TypeRevised

Effective DateJan 1, 2022

Next Review DateMar 19, 2025

Key ActionFile CPT 92133 with an appropriate ICD-10 diagnosis code from the policy attachment and follow correct coding guidelines regarding global vs component billing.

SourceLink

POLICY UPDATE CHANGES

The CPT code 92133 description was revised effective 1/1/2025 to specify optic nerve.

1CPT code designated as medically necessary in policy

5Listed clinical indications supporting posterior segment OCT use

0Medical criteria specified (policy states Not applicable)

4Provider updates published (2021-2025)

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Coverage Criteria for Posterior Segment OCT (SCODI)

Medically necessary indications for posterior segment OCT

Posterior segment OCT (SCODI) is considered reasonable and necessary for the diagnosis and management of the following clinical situations when accompanied by an appropriate ICD-10 diagnosis code:

Covered indications: Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases which involve changes in the optic nerve, subretinal and intraretinal changes, vitreo-retinal relationships, and changes in the nerve fiber layer; diagnose early glaucoma and monitor glaucoma treatment; differentiate causes of other optic nerve disorders when a diagnosis is in doubt; diagnose and manage the patient's condition when visual field results are insufficient or when reliable visual field testing cannot be performed due to visual, physical, mental, or age constraints; reconcile discrepancies between the clinical appearance of the optic nerve and visual fields; detect further loss of optic nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss; follow glaucoma suspects.

These indications are listed as reasonable and necessary in the policy.

Other indications not filed with one of the specified ICD-10 diagnosis codes in the policy attachment are considered not medically necessary.

Any use of CPT 92133 for indications not matched to one of the ICD-10 diagnosis codes listed in the attachment is considered not medically necessary.

Coding and Diagnosis Linkage

Medically necessary CPT codeCPTCovered

92133

Scanning Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (Text Revised Effective 1/1/2025)

ICD-10 linkage (must accompany CPT 92133)

RequirementCPT 92133 must be filed with one of the ICD-10 diagnosis codes listed in the policy attachment

ConsequenceClaims for CPT 92133 filed without an approved ICD-10 diagnosis code from the attachment are considered not medically necessary

Attachment locationICD-10 diagnosis codes are provided in the policy attachment referenced in the document

Coding noteFollow correct coding guidelines regarding global service vs professional/technical component when filing

Provider Actions, Billing, and Documentation

Prior Authorization

Prior authorization is not applicable for this policy.

Note

Billing Rule

Coding and Documentation

File CPT 92133 with an appropriate ICD-10 diagnosis code and follow global vs component billing guidance. If billing the global service, submit the full CPT 92133; if billing only the professional (interpretation) or technical (imaging) component, follow applicable modifier and payer-specific guidance.

CPT 92133: Scanning computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

Background

Scanning computerized ophthalmic diagnostic imaging (SCODI), commonly performed as optical coherence tomography (OCT), is a non-invasive, non-contact imaging modality that produces high-resolution cross-sectional tomographic images of ocular structures for anterior and posterior segment evaluation. Posterior segment OCT provides detailed visualization of the optic nerve, retinal nerve fiber layer, macula, retinal and choroidal layers, and vitreo‑retinal relationships, supporting early detection of optic nerve and retinal changes, glaucoma diagnosis and monitoring, differentiation of optic nerve disorders, and surgical planning.

Definitions

SCODI / OCT — definition and clinical role

DefinitionScanning Computerized Ophthalmic Diagnostic Imaging (SCODI), e.g., optical coherence tomography (OCT), is a non-invasive, non-contact imaging technique producing high-resolution cross-sectional tomographic images of ocular structures for anterior and posterior segment evaluation.

Clinical utilityEnables earlier detection of optic nerve and retinal nerve fiber layer pathologic changes before visual field loss, aiding diagnosis and management of glaucoma and glaucoma suspects.

Anatomic assessmentPermits high-resolution assessment of retinal and choroidal layers, macular thickness measurement, and detection of retinal edema-related thickening.

Surgical planningDisplays vitreo-retinal and vitreo-papillary relationships to assist vitreo-retinal surgical planning and assessment.