As imaging technology evolves for age-related macular degeneration (AMD), especially with the availability of optical coherence tomography (OCT)-angiography and office-based electroretinography (ERG), optometrists must be aware of the rules governing their use.
Rule No. 1: Document Medical Necessity
The OD must clearly document clinical findings and justify imaging with International Classification of Diseases (ICD)-10 code codes, such as H35.31-H35.32
Rule No. 2: Use Condition Characteristics
To select the proper ICD-10 code for AMD, the optometrist must determine the type, severity, and laterality. For example, if the patient has neovascular AMD in their left eye, the ICD-10 code would be H35.32.
Rule No. 3: Don't Pair
The OD should not routinely bill 92250 (fundus photography) and 92134 (ocular coherence tomography) together unless the doctor clearly establishes distinct medical necessity and uses the correct modifiers. Code 92250 cannot be used with 92134 without modifier -59 and clinical justification. (Most payors do not deem codes 92134 and 92250 medically necessary when processed on the same day.) Additionally, OCT and OCT-A are generally not billable together on the same day.
Rule No. 4: Assess Coverage for OCT-A
Code 92229 (OCT-A), used to determine choroidal neovascularization without dye and conversion risk from dry AMD to wet AMD, has a growing payor coverage, but it is not universal. Therefore, the optometrist should be sure to check the patient’s plan and Local Coverage Determinations for patient coverage.
Rule No. 5: Document the Test Order
When using 92273 (full-field ERG) and/or 92274 (multifocal ERG), documentation of the test order is imperative. An example of a test order is “mfERG ordered to evaluate macular function in advanced dry AMD with unexplained acuity loss.”
Rule No. 6: Include an Illustration
The 99202 (extended ophthalmoscopy) submission should include a hand-drawn or digital fundus illustration of the peripheral findings or hemorrhages. Specifically, the illustration should include clock hours and location of pathology, depict lesions and standardized retinal diagram symbols. Also, scleral depression should be noted if done.
Rule No. 7: Sign the Interpretation or Report
The OD should always include a signed interpretation/report and clinical plan based on image findings.
Rule A Win-Win
By staying informed on billing guidelines and ensuring robust documentation, optometrists can confidently support the high-level care AMD patients require, while protecting the financial health of their practice. OM
