Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27529

Scanning Computerized Ophthalmic Diagnostic Imaging

L27529

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Glaucoma is a leading cause of blindness, and a disease for which treatment methods clearly are available and in common use. Glaucoma also is diagnostically challenging. Almost 50% of glaucoma cases remain undetected. Elevated intraocular pressure is a clear risk factor for glaucoma, but over 30% of those suffering from the disease have pressures in the normal range. Further, most patients having abnormally high pressures will never suffer glaucomatous damage to their vision.

Glaucoma commonly causes a spectrum of related eye and vision changes, including erosion of the optic nerve and the associated retinal nerve fibers, and also loss of peripheral vision. A diagnosis of glaucoma seldom is made on the basis of a single clinical observation, but instead relies upon analysis of an assemblage of clinical data, including: optic nerve, retinal nerve fiber, and anterior chamber structure, as well as looking for hemorrhages of the optic nerve, pigment in the anterior chamber, and, especially visual field loss. Each of these methods has its own strengths and limitations, and none is immune to error -- thus the dependence upon multiple observations. Careful reliance upon all available clinical data can allow early treatment and can prevent unnecessary end-stage therapies.

Scanning Computer Ophthalmic Diagnostic Imaging (SCODI) allows earlier detection of those patients with normal tension glaucoma and more sophisticated analysis for ongoing management. Because SCODI detects glaucomatous damage to the nerve fiber layer or optic nerve of the eye, it can distinguish patients with glaucomatous damage irrespective of the status of intraocular pressure (IOP). It may separate patients with elevated IOP and early glaucoma damage from those without glaucoma.

SCODI includes the following tests:

• Confocal Laser Scanning Ophthalmoscopy (topography)

• Scanning Laser Polarimetry, nerve fiber analyzer

• Optical Coherence Tomography (OCT)

The two forms of scanning computerized ophthalmic diagnostic imaging tests that currently exist are confocal laser scanning ophthalmoscopy (topography) and scanning laser polarimetry. Although these techniques are different, their objective is the same in that they allow for early detection of glaucoma damage to the nerve fiber layer.

Confocal scanning laser ophthalmoscopy (topography) uses stereoscopic videographic digitized images to make quantitative topographic measurements of the optic nerve head and surrounding retina.

Scanning laser polarimetry measures change in the linear polarization of light (retardation). It uses both a polarimeter (an optical device to measure linear polarization change) and a scanning laser ophthalmoscope, to measure the thickness of the nerve fiber layer of the retina.

In progressive glaucoma there is an increasing loss of retinal nerve fibers, therefore, a decrease in nerve fiber thickness occurs. Scanning computerized ophthalmic diagnostic imaging allows earlier detection of glaucoma and more sophisticated analysis for ongoing management. These tests can distinguish patients with glaucomatous damage irrespective of the status of the IOP. These tests also provide more precise methods of observation of the optic nerve head and can more accurately reveal subtle glaucomatous changes over the course of time than visual field's and/or disc photos. This allows earlier and more efficient efforts of treatment toward the disease process.

Optical coherence tomography (OCT) is a non-invasive, non-contact imagining technique. OCT produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of retinal disease.

Indications

Glaucoma

Technological improvements have rendered SCODI as a valuable diagnostic tool in the diagnosis and treatment of glaucoma. These improvements enable discernment of changes of the nerve fiber even in advanced cases of glaucoma.

It is expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having glaucoma.

Retinal Disorders

Retinal disorders are the most common causes of severe and permanent vision loss. These technologies are valuable tools for the evaluation and treatment of patients with retinal disease, especially macular abnormalities.

These imaging techniques are useful tools to measure the effectiveness of therapy, and in determining the need for ongoing therapy, or the safety of cessation of therapy.

It is expected that only one exam/eye/2 months would be required to manage the patient whose primary ophthalmological condition is related to a retinal disease.  However, for those patients who are undergoing active treatment for macular degeneration or diabetic retinopathy one exam/eye/month may be appropriate for the management of their disease.

The use of fluorescein angiography, indocyanine green angiography and SCODI to study the patient’s same eye per clinical encounter will NOT be authorized. However, SCODI and fluorescein angiography may be obtained on the patient’s same eye per clinical encounter if the medical record substantiates the need for both studies.

Anterior Segment Disorders

SCODI may be used to examine the structures in the anterior segment structures of the eye. However, it is still seen as experimental/investigational except in the following:

1. Narrow angle, suspected narrow angle, and mixed narrow and open angle glaucoma
2. Determining the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction
3. Iris tumor
4. Presence of corneal edema or opacity that precludes visualization or study of the anterior chamber
5. Calculation of lens power for cataract patients who have undergone prior refractive surgery. Payment will only be made for the cataract codes as long as additional documentation is available in the patient record of their prior refractive procedure. Payment will not be made in addition to A-scan or IOL master.
6. Certain exceptions that must be determined on a case-by-case basis with the appropriate documentation.

Diagnostic Tests and X-rays

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
4. Medical record documentation (e.g., office/progress notes) maintained by the performing physician must indicate the medical necessity of the scanning computerized ophthalmic diagnostic imaging. Additionally, a copy of the test results, computer analysis of the data, and appropriate data storage for future comparison in follow-up exams must be maintained in the patient's file.
5. If bilateral studies are reported, the documentation maintained by the provider must demonstrate medical need for the performance of the test for each eye.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

1. Only two exams/eye/year are allowed for the patient who has or is suspected of having glaucoma.
   
   
2. Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease.
   
   

3. One exam/eye/month is allowed for the patient who is undergoing active treatment for macular degeneration or diabetic retinopathy.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27529

07/31/2008

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