March 2003
MedicareGuidelines for Vision
Scanning Computerized Ophthalmic Diagnostic Imaging (92135) Scanningcomputerizedophthalmicdiagnosticimagingallows for early detection of glaucomadamage to the nerve fiber layer or optic nerve of the eye. It is the goal of these diagnosticimagingtests to discriminateamong patients with normal intraocularpressures (lOP) who have glaucoma,patients with elevated lOP who have glaucoma,and patientswith elevated lOP who do not have glaucoma. Two forms of scanning computerizedophthalmic diagnostic imagingtests that currently exist are confocal laser scanningopthalmoscopy(topography)and scanninglaser polarimetry.Althoughthese techniquesare different,their objectiveisthe same. Confocal scanninglaser opthalmoscopy(topography)uses 32 tomographicimagesto make quantitative topographicmeasurementsof the optic nerve head and surroundingretina. Scanninglaser polarimetrymeasureschange in the linearpolarizationof light(retardation).It uses a polarimeter,an optical device to measure linearpolarizationchangeand a scanninglaser ophthalmoscope togetherto measurethe thicknessof the nerve fiber layerof the retina. Indications and Limitations of Coverage and/or Medical Necessity Scanningcomputerizedophthalmicdiagnosticimagingallowsearlier detectionof glaucomaand more sophisticatedanalysisfor ongoingmanagement.These tests can distinguishpatients with glaucomatous damage irrespectiveof the status of the lOP. These tests also provide more precisemethods of observation of the optic nerve head and can more accurately reveal subtle glaucomatouschanges over the course of follow-upexams than visualfield and/or disc photoscan, thus allowingfor earlier and more efficientefforts of treatment toward the diseaseprocess. Medicare of Florida will consider scanning computerizedophthalmic diagnosticimagingmedically reasonableand necessaryunder the followingcircumstances: 1. The patient presents with "mild" glaucomatous damage or "suspect glaucoma" as demonstrated by any of the following:
.
Intraocularpressure;;::22mmHgas measuredby applanation
. . . . .
Symmetricor verticallyelongatedcup enlargement,neural rim intact,cup/discratio> 0.4 Focal optic disc notch Opticdisc hemorrhageor historyof optic disc hemorrhage Nasal step peripheralto 20 degreesor smallparacentralor arcuate scotoma Mildconstrictionof visualfieldisopters
Note: Because of the slow diseaseprogressionof patientswith "suspect glaucoma"or those with "mild" glaucomatousdamage,the use of scanningcomputerizedophthalmicdiagnostic imagingat aftequency of> 1/yearis not expected. 2. The patient presents with "moderate" glaucomatous damage as demonstratedby any of the following:
.
Enlarged optic cup with neural rim remainingbut sloped or pale, cup to disc ratio> 0.5 but < 0.8
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Medicare Guidelines forVision
March 2003
.
Definitefocal notch with thinningof the neural rim
.
Defmite glaucomatousvisual field defect (e.g., arcuate defect, nasal step, paracentral scotoma,or generaldepression. Note: Patients with "moderate damage"may be followedwith scanningcomputerizedophthalmic diagnosticimagingand/or visualfields.One or two tests of either per year may be appropriate. If both scanningcomputerizedophthalmicdiagnosticimagingand visual field tests are used, only one of each test would be considered medicallynecessary, as these tests provideduplicativeinformation.
Scanningcomputerized ophthalmic diagnostic imagingis not considered medicallyreasonable and necessary for patients with "advanced" glaucomatous damage. Instead, visual field testing should be performed. (Late in the course of glaucoma, when the nerve fiber layer has been extensively damaged,visualfieldsare more likelyto detect smallchangesthan are changesin scanningcomputerizedophthalmicdiagnosticimaging). The patient with "advanced" glaucomatousdamagewould demonstrateany of the following . Diffuseenlargementof optic nerve cup, with cup to disc ratio> 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
Loss of central visualacuity,with temporalislandremaining In addition,scanningcomputerizedophthalmicdiagnosticimagingis not consideredmedicallyreasonableand necessarywhen performedto provideadditionalconfmnatoryinformationregardinga diagnosis,whichhas alreadybeen determined. HCPCS Codes
92135
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Scanningcomputerizedophthalmicdiagnosticimaging(e.g., scanninglaser)with interpretationand report, unilateral
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March2003
MedicareGuidelines for Vision
ICD-9 Codesthat Support Medical Necessity 362.85 Retinalnerve fiber bundledefects 364.22 Glaucomatocycliticcrises 364.53 Pigmentaryirisdegeneration 364.73 Goniosynechiae 364.74 Adhesionsand disruptionsof pupillarymembranes 364.77 Recessionof chamberangle 365.00-365.04 Borderlineglaucoma[glaucomasuspect] 365.10-365.15 Open-angleglaucoma 365.20-365.24 Primaryangle-closureglaucoma 365.31-365.32 Corticosteroid-inducedglaucoma 365.41-365.44 Glaucomaassociatedwith congenitalanomalies,dystrophies,and systemic syndromes 365.51-365.59 Glaucomaassociatedwith disordersof the lens 365.60-365.65 Glaucomaassociatedwith other ocular disorders 365.81-365.89 Other specifiedformsof glaucoma 365.9 Unspecifiedglaucoma 368.40 Visualfielddefect, unspecified 368.41 Scotomainvolvingcentral area 368.42 Scotomaof blind spot area 368.43 Sectoror arcuate defects 368.44 Other localizedvisualfielddefect 368.45 Generalizedcontractionor constriction 377.00-377.04 Papilledema 377.9 Unspecifieddisorderof optic nerve and visualpathways 743.20-743.22 Buphthalmos Reasonsfor Denial When performedfor indicationsother than those listedin the "Indicationsand Limitationsof Coverage and/or MedicalNecessity" sectionof this policy. Scanningcomputerizedophthalmic diagnosticimagingdoes not have case controlled studies which demonstratea defmed role in makingclinicaltreatment decisionsregardingdiseasesother than those listed in the "ICD-9 Codes That SupportMedicalNecessity" section of this policy. Until this technology is proven to be as specific and sensitive a method for followingother diseases as existing tests, it shouldnot supersedecurrenttechnologies(e.g., fluoresceinangiography). Scanningcomputerizedophthalmic diagnosticimagingis not medicallynecessary when performed solelyto provide additionalconfmnatory informationregardinga diagnosisthat has alreadybeen determined. Coding Guidelines HCPCS code 92135 is considered a unilateral service. The provider should indicate which eye was treated with either a LT or RT modifier on the CMS-1500 claim form.
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MedicareGuidelines for Vision
March2003
DocumentationRequirements Medical record documentation(e.g., office/progressnotes) maintainedby the performingphysician must indicate the medical necessity of the scanning computerizedophthalmicdiagnostic imaging. Additionally,a copy of the test results, computer analysisof the data, and appropriatedata storage for future comparisonin follow-upexams is required. If both eyes are treated, the documentation maintainedby the provider must demonstratemedicalneed for the performanceof the test for each eye. OtherComments In the UnitedStates, glaucomais the second leadingcause of blindnessand the most ftequent cause amongAftican-Americans.The managementof glaucomaincludesthe early detectionand treatment to be able to arrest the lossof vision.Detection depends on the abilityto recognizethe early clinical manifestationsof the variousglaucomas. Glaucomais not a singledisease process. Rather, it is a large group of disordersthat are characterized by widely diverse clinicaland histopathologicalmanifestations.The commondenominatorof all the glaucomasis a characteristicoptic neuropathy,which derives ftom variousrisk factors including increased intraocular pressure (lOP). Althoughelevated lOP is clearly the most ftequent causative risk factor for glaucomatousoptic atrophy, attempts to defme glaucomaon the basis of ocular tensionare no longeradvised. Almost50 percent of patientswith glaucomaremainundetected.Thirtypercent of glaucomapatients are those with normallOP. Furthermore,there are patientswith elevated lOP that do not necessarily have glaucoma. Dependenceupon visual field tests to separate those patients with glaucomaftom those withoutthe disease would stillmiss a large number of patients. This is because as many as 50 percent of the one million ganglioncells that enter each optic nerve must be lost before there is glaucomatousvisual field defect created. Additionally,some patients cannot performvisual fieldtesting reliably,as it is a subjectivetest requiringa certain levelof alertnessand cooperation. AdvanceNoticeStatement Advance BeneficiaryNotice (ABN) isrequired in the event the servicemay be deniedor reduced for reasonsof medicalnecessity. Ophthalmoscopy
(92225 and 92226)
Extended ophthalmoscopyis the inspectionof the interiorof the eye with the pupil dilated.This inspection is fundamentalto diagnosisand permitsvisualizationof the optic disk, arteries,veins,retina, choroid,and media and is directed toward the conditionof the vessels,the color ofthe tissueand the character of the optic nerve. The three methodsof viewingthe ocular fundus includedirect ophthalmoscopy,by whicha magnificationof about 15Xis obtained;indirectophthalmoscopy, by whicha larger field is obtained, but with magnificationof two to three X; and biomicroscopycombinedwith a lensto neutralizecornealreftactingpower.
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First Coast Service Options, Inc. . Medicare Education and Outreach
