Scanning Computerized Ophthalmic Diagnostic Imaging (92135) 2003 Medicare Guidelines for Vision...
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March 2003 MedicareGuidelines for Vision
Scanning Computerized Ophthalmic Diagnostic Imaging (92135)Scanningcomputerizedophthalmicdiagnosticimagingallowsfor early detection of glaucomadam-age to the nerve fiber layeror opticnerve of the eye. It is the goalof these diagnosticimagingtests todiscriminateamongpatients with normal intraocularpressures (lOP) who have glaucoma,patientswith elevated lOP who have glaucoma,and patientswithelevatedlOP who do not have glaucoma.
Two forms of scanning computerizedophthalmicdiagnostic imagingtests that currently exist areconfocal laser scanningopthalmoscopy(topography)and scanninglaser polarimetry.Althoughthesetechniquesare different,their objectiveisthe same.
Confocal scanninglaser opthalmoscopy(topography)uses 32 tomographicimagesto make quantita-tive topographicmeasurementsof the optic nerve head and surroundingretina.
Scanninglaser polarimetrymeasureschange in the linearpolarizationof light(retardation).It uses apolarimeter,an optical device to measure linearpolarizationchangeand a scanninglaserophthalmo-scope togetherto measurethe thicknessof the nerve fiber layerof the retina.
Indications and Limitations of Coverage and/or Medical Necessity
Scanningcomputerizedophthalmicdiagnosticimagingallowsearlier detectionof glaucomaand moresophisticatedanalysisfor ongoingmanagement.These tests can distinguishpatients with glaucoma-tous damage irrespectiveof the status of the lOP. These tests also providemore precisemethods ofobservation of the optic nerve head and can more accurately reveal subtle glaucomatouschangesover the course of follow-upexams than visualfield and/or disc photoscan, thus allowingfor earlierand more efficienteffortsof treatment towardthe diseaseprocess.
Medicare of Florida will consider scanningcomputerizedophthalmicdiagnosticimagingmedicallyreasonableand necessaryunder the followingcircumstances:
1. The patient presentswith "mild" glaucomatous damage or "suspect glaucoma" as demon-strated by any of the following:
. Intraocularpressure;;::22mmHgas measuredby applanation
. Symmetricor verticallyelongatedcup enlargement,neuralrim intact,cup/discratio> 0.4
. Focal opticdiscnotch
. Opticdisc hemorrhageor historyof opticdischemorrhage
. Nasal step peripheralto 20 degreesor smallparacentralor arcuate scotoma
. Mildconstrictionof visualfieldisoptersNote: Because of the slowdiseaseprogressionof patientswith "suspect glaucoma"or thosewith "mild" glaucomatousdamage,the use of scanningcomputerizedophthalmicdiagnosticimagingat aftequency of> 1/yearis not expected.
2. The patient presentswith "moderate" glaucomatous damage as demonstratedby any of thefollowing:
. Enlargedoptic cup with neural rim remainingbut slopedor pale, cup to disc ratio> 0.5but < 0.8
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. Definitefocalnotch withthinningof the neural rim
. Defmite glaucomatousvisual field defect (e.g., arcuate defect, nasal step, paracentralscotoma,or generaldepression.
Note: Patientswith "moderate damage"maybe followedwithscanningcomputerizedoph-thalmicdiagnosticimagingand/or visualfields.One or two tests of either per year may beappropriate. If both scanningcomputerizedophthalmicdiagnosticimagingand visual fieldtests are used, only one of each test would be considered medicallynecessary, as thesetests provideduplicativeinformation.
Scanningcomputerizedophthalmicdiagnostic imagingis not consideredmedicallyreasonable andnecessary for patients with "advanced" glaucomatous damage. Instead, visual field testing shouldbe performed. (Late in the course of glaucoma,when the nerve fiber layer has been extensivelydamaged,visualfieldsare more likelyto detect smallchangesthan are changesin scanningcomput-erizedophthalmicdiagnosticimaging).
The patientwith "advanced" glaucomatousdamagewoulddemonstrateany of the following. Diffuseenlargementof opticnerve cup, with cup to discratio> 0.8. Wipe-out of all or a portion of the neural retinal rim. Severegeneralizedconstrictionof isopters(Le.,GoldmannI4e, < 10degreesof fixation). Absolutevisualfielddefectsto within 10degreesof fixation. Severe generalized reduction of retinal sensitivity. Lossof centralvisualacuity,withtemporalislandremaining
In addition,scanningcomputerizedophthalmicdiagnosticimagingis not consideredmedicallyrea-sonableand necessarywhen performedto provideadditionalconfmnatoryinformationregardingadiagnosis,whichhas alreadybeen determined.
92135 Scanningcomputerizedophthalmicdiagnosticimaging(e.g., scanninglaser)with inter-pretationand report, unilateral
March2003 MedicareGuidelines for Vision
ICD-9Codesthat SupportMedical Necessity362.85 Retinalnerve fiberbundledefects364.22 Glaucomatocycliticcrises364.53 Pigmentaryirisdegeneration364.73 Goniosynechiae364.74 Adhesionsand disruptionsof pupillarymembranes364.77 Recessionof chamberangle365.00-365.04 Borderlineglaucoma[glaucomasuspect]365.10-365.15 Open-angleglaucoma365.20-365.24 Primaryangle-closureglaucoma365.31-365.32 Corticosteroid-inducedglaucoma365.41-365.44 Glaucomaassociatedwith congenitalanomalies,dystrophies,and systemic
syndromesGlaucomaassociatedwith disordersof the lensGlaucomaassociatedwith other oculardisordersOther specifiedformsof glaucomaUnspecifiedglaucomaVisualfielddefect, unspecifiedScotomainvolvingcentral areaScotomaof blindspot areaSectoror arcuate defectsOther localizedvisualfielddefectGeneralizedcontractionor constrictionPapilledemaUnspecifieddisorderof opticnerve and visualpathwaysBuphthalmos
When performedfor indicationsother than those listedin the "Indicationsand Limitationsof Cover-age and/orMedicalNecessity"sectionof thispolicy.
Scanningcomputerizedophthalmicdiagnosticimagingdoes not have case controlledstudies whichdemonstratea defmedrole in makingclinicaltreatment decisionsregardingdiseasesother than thoselisted in the "ICD-9 Codes That SupportMedicalNecessity" section of this policy. Until this tech-nology is proven to be as specific and sensitivea method for followingother diseases as existingtests, it shouldnot supersedecurrenttechnologies(e.g., fluoresceinangiography).
Scanningcomputerizedophthalmicdiagnosticimagingis not medicallynecessary when performedsolelyto provideadditionalconfmnatory informationregardinga diagnosisthat has alreadybeen de-termined.
HCPCS code 92135 is considered a unilateral service. The provider should indicate which eye wastreated with either a LT or RT modifier on the CMS-1500 claim form.
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Medical record documentation(e.g., office/progressnotes) maintainedby the performingphysicianmust indicate the medical necessity of the scanning computerizedophthalmicdiagnostic imaging.Additionally,a copy of the test results, computer analysisof the data, and appropriatedata storagefor future comparisonin follow-upexams is required. If both eyes are treated, the documentationmaintainedby the provider must demonstratemedicalneed for the performanceof the test for eacheye.
In the UnitedStates,glaucomais the second leadingcause of blindnessand the most ftequent causeamongAftican-Americans.The managementof glaucomaincludesthe earlydetectionand treatmentto be able to arrest the lossof vision.Detectiondependson the abilityto recognizethe earlyclinicalmanifestationsof the variousglaucomas.
Glaucomais not a singledisease process. Rather, it is a large groupof disordersthat are character-ized by widelydiverseclinicaland histopathologicalmanifestations.The commondenominatorof allthe glaucomasis a characteristicoptic neuropathy,which derives ftom variousrisk factors includingincreased intraocularpressure (lOP). Althoughelevated lOP is clearly the most ftequent causativerisk factor for glaucomatousoptic atrophy, attempts to defme glaucomaon the basis of ocular ten-sionare no longeradvised.
Almost50 percent of patientswith glaucomaremainundetected.Thirtypercent of glaucomapatientsare those with normallOP. Furthermore,there are patientswithelevatedlOP that do not necessarilyhave glaucoma.
Dependenceupon visual field tests to separate those patients with glaucomaftom those withoutthediseasewould stillmiss a largenumberof patients.This is because as many as 50percent of the onemillionganglioncells that enter each optic nerve must be lost before there is glaucomatousvisualfield defect created. Additionally,some patients cannot performvisual fieldtesting reliably,as it is asubjectivetest requiringa certain levelof alertnessand cooperation.
Advance BeneficiaryNotice (ABN)isrequiredinthe event the servicemay be deniedor reducedforreasonsof medicalnecessity.
Ophthalmoscopy (92225 and 92226)
Extended ophthalmoscopyis the inspectionof the interiorof the eye with the pupil dilated.This in-spectionis fundamentalto diagnosisand permitsvisualizationof the opticdisk, arteries,veins,retina,choroid,and mediaand is directed towardthe conditionof the vessels,the color ofthe tissueand thecharacter of the optic nerve. The three methodsof viewingthe ocular fundus includedirectophthal-moscopy,by whicha magnificationof about15Xis obtained;indirectophthalmoscopy,bywhichalarger field is obtained,but with magnificationof two to three X; and biomicroscopycombinedwitha lensto neutralizecornealreftactingpower.
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