Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) — Posterior Segment
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Policy governing the medical necessity and coding for posterior segment scanning computerized ophthalmic diagnostic imaging (e.g., OCT) for Medicare Advantage and commercial members; affects providers performing and billing posterior segment SCODI in the applicable plan population.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Indications
Covered when ANY of the following clinically indicated reasons are present:
Aggregated from policy indications.
Coverage determinations for SCODI services are governed by the member's specific plan documents. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a particular diagnostic test is covered under that contract, as benefits may vary between groups and plans.
Under the Medical Criteria section the policy states Not applicable. There are no explicit items listed in this document as "not medically necessary."
Coding
| 92133 | Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; optic nerve |
| 92134 | Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina |
| 92137 | Computerized ophthalmic diagnostic imaging (eg, optical coherence tomography [OCT]), posterior segment, with interpretation and report, unilateral or bilateral; retina, including OCT angiography |
Provider Actions & Billing Requirements
Coverage & Billing Verification
Benefits may vary between groups/contracts. Verify member-specific coverage by checking the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before providing or billing for diagnostic testing.
- Coverage depends on group/contract benefits; verify Evidence of Coverage or Subscriber Agreement prior to service.
- CPT codes 92133, 92134, and 92137 must be filed with the appropriate ICD-10 diagnosis code(s) as specified in the policy attachment.
- Follow correct coding guidelines when billing for global services or when filing professional (26) and technical (TC) components.
Prior Authorization
Prior authorization is not applicable under this policy; however, always verify member-specific contract requirements as some groups or plans may have different administrative requirements.
Coding Requirements
File CPT 92133, 92134, and 92137 only when accompanied by an appropriate ICD-10 diagnosis code from the policy's ICD-10 lists. Ensure CPT/ICD-10 pairings match the code-specific diagnosis lists and include the correct component modifiers when applicable.
- CPT 92133 — include applicable ICD-10 diagnosis code from the 92133 list.
- CPT 92134 — include applicable ICD-10 diagnosis code from the 92134 list.
- CPT 92137 — include applicable ICD-10 diagnosis code from the 92137 list.
- Include modifier 26 or TC when billing professional or technical components separately, per coding guidance.
Background
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), for example optical coherence tomography (OCT), is a non‑invasive, non‑contact imaging technique that produces high‑resolution cross‑sectional tomographic images of the eye. Posterior segment SCODI provides detailed visualization of the retina, choroid, optic nerve, and vitreoretinal relationships to aid in diagnosis and management of posterior ocular disease, including earlier detection of optic nerve and retinal nerve fiber layer changes, assessment of macular pathology, guidance for surgical planning, and monitoring of glaucoma and retinal conditions.
Definitions
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