Are you an ophthalmologist struggling to get paid for the essential computerized diagnostic scans on the first try? Well, the reason for the denial can be as simple as missing a component billing modifier (26, TC), misusing a bilateral procedure modifier (50), or inadequate documentation.
Most of the time, you can prevent these denials by strengthening your billing best practices. But this cannot happen without understanding the procedural code. Thus, this guide will discuss everything you need to know about CPT code 92134. So, continue reading!
CPT Code 92134 – Description
CPT code 92134 covers computerized diagnostic imaging of the retina in the back part (posterior segment) of the patient’s eye. The ophthalmologist typically employs the optical coherence tomography (OCT) imaging technique.
It also includes data interpretation and report generation. Besides, the provider may perform the service on one or both eyes.
Scenarios Where CPT Code 92134 is Applicable
Let’s review a few real-world clinical scenarios where CPT 92134 applies:
Wet Age-Related Macular Degeneration (AMD) Monitoring
Picture a 68-year-old female patient with known wet AMD in the left eye. She visits the ophthalmology clinic for a scheduled follow-up.
The ophthalmologist performs an OCT scan to determine the thickness of the retina. Besides, during the procedure, the provider checks for any new subretinal fluid or hemorrhage.
Here, CPT code 92134 applies.
Diabetic Retinopathy Management
Assume a 50-year-old male patient with type 2 diabetes who comes for an annual eye examination. Upon dilation, the healthcare practitioner notes microaneurysms and suspects macular edema.
As a result, a computerized retinal scan is performed to obtain a cross-sectional view of the macula. The findings will help measure the internal layers for swelling.
The ophthalmologist should report CPT code 92134 to bill for the scan.
Retinal Vein Occlusion (RVO) Evaluation
Imagine a 63-year-old female patient with a history of hypertension who comes to the ophthalmology clinic. She complains about experiencing sudden, painless blurred vision in her right eye for the past three days.
Therefore, the physician performs an OCT scan covered under CPT code 92134 to assess the macular edema secondary to the occlusion.
Applicable Modifiers for CPT Code 92134
Listed below are some of the applicable modifiers for CPT 92134:
Modifier 26
What happens when you only interpret the OCT scan, but do not perform the procedure yourself? You report CPT code 92134 with modifier 26 to indicate that you are billing for the professional component only.
Modifier TC
Hospitals or ophthalmology clinics that own the equipment, resources, and supplies needed to perform the OCT scan typically report CPT code 92134 with modifier TC. It highlights to the payer that you are billing only for the technical component of the procedure.
Please note that modifier 50 should not be used to indicate to the payer that the diagnostic scan was performed on both eyes. This is because code 92134 is inherently bilateral, and the reimbursement rate remains the same whether the procedure was performed on one eye or both.
CPT Code 92134 – Billing & Reimbursement Guidelines
The following are some of the essential billing guidelines for CPT 92134:
Do Not Report CPT Codes 92133 and 92134 On the Same Day
You cannot report CPT code 92134 on the same day for the same patient as CPT code 92133. The reason? These procedural codes are mutually exclusive and cannot be unbundled with modifier 59.
Understand the Allowed Billable Frequency
As per the Centers for Medicare and Medicaid (CMS) guidelines, you cannot bill CPT code 92134 more than once every two months for the same patient.
So, what happens when you perform it more than the allowable frequency? Federal programs and even some private payers may deem the billed service medically unnecessary, leading to non-payment
Fulfill Documentation Requirements
Comprehensive documentation is the secret ingredient that helps prove the medical necessity and performance of the billed service. Here’s a checklist to help you ensure timely reimbursement against CPT code 92134:
- Explicitly state that you utilized OCT technology.
- Mention the specific quantitative and qualitative data findings in the report. For example, central subfield thickness: 485μm, presence of intraretinal cysts and subfoveal fluid, etc.
- Explain whether the condition is stable, improved, or worsened in comparison to the previous scan.
- Describe the findings’ impact on the treatment plan. For example, the persistent fluid justifies the next anti-VEGF injection.
Summary
With that said, it is time to conclude this guide. However, before bidding farewell, let’s quickly summarize the key takeaways!
CPT code 92134 covers an OCT scan of the retina in the posterior segment (back part) of one or both eyes with interpretation and report generation.
For billing either technical (TC) or professional (26) components of the service, you must append the relevant modifier. However, you cannot append modifier 59 to bill CPT codes 92133 and 92134 together, since they are mutually exclusive.
Are these details confusing you? If yes, consider outsourcing ophthalmology billing services to professionals like MediBillMD.
