Most Medicare carriers revised coverage determination at the end of August for billing Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI, or “OCT”) and other diagnostic services together for the management of glaucoma.
Retinal images, extended ophthalmoscopy and B-scan cannot be billed in conjunction with SCODI.
For suspect or mild glaucoma (stage 1), fields and SCODI are OK:
- no detectable VF defect;
- “mild” generalized reduction in retinal sensitivity;
- “mild” constriction of isopters;
- nasal step peripheral to 20 degrees; and/or
- small relative defects of the Bjerrum area, peripheral to 9 degrees.
- symmetric or vertically elongated cup enlargement; neural rim intact, rim: disc ratio > 0.2; cup:disc ratio <0.8;
- focal notch; rim:disc ratio > 0.2; cup:disc ratio <0.8
- no definite pathologic cupping; and/or
- previously observed disc hemorrhage.
For moderate glaucoma (stage 2), SCODI and Fields together or within 3 months apart are not allowed. Moderate is defined as:
- “moderate” generalized reduction in retinal sensitivity;
- “moderate” constriction of isopters absolute defects to within 9 degrees of fixation; and/or
- temporal wedge.
- enlarged optic nerve cup with neural rim remaining but sloped or pale;
- focal notches with rim:disc ratio > 0.1 but <0.2; cup:disc ratio > 0.8 but <0.9; and/or
- prominent lamina cribrosa
SCODI is not considered medically necessary for patients with advanced glaucoma (stage 3.) At that point, Visual Fields are the accepted management option. Advanced is defined as:
- “severe” generalized reduction in retinal sensitivity;
- “severe” constriction of isopters (i.e., 14e <10 degrees);
- absolute defects to within 3 degrees of fixation;
- loss of central acuity; and/or
- temporal island remains.
- diffuse enlargement of optic nerve cup; rim:disc ratio <0.1; cup:disc ratio > 0.9; and/or
- wipe out of all or a portion of the neuroretinal rim.
ICD-10-CM requires stage to be included in the diagnosis of glaucoma.
SCODI is the accepted method of management of retinal disorders as well.