SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

NHIC, Corp.
Contractor Number ^{back to top}
31142
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L10804

LCD Title ^{back to top}
SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (SCODI)

Contractor's Determination Number ^{back to top}


AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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.

CMS National Coverage Policy ^{back to top}
· Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examination and screening tests performed in the absence of signs or symptoms from coverage. · Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary. · Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Primary Geographic Jurisdiction ^{back to top}
Massachusetts Maine New Hampshire Vermont

Oversight Region ^{back to top}
Region I

Original Determination Effective Date ^{back to top}
For services performed on or after 02/01/2000

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 10/01/2007

Revision Ending Date ^{back to top}
09/30/2008

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) allows for earlier detection of optic nerve and retinal nerve fiber layer pathologic changes before there is visual field loss. When appropriately used in the management of the glaucoma patient or glaucoma suspect, therapy can be initiated before there is irreversible loss of vision. This imaging technology provides the capability to discriminate among patients with normal intraocular pressures who have glaucoma, patients with elevated intraocular pressure who have glaucoma, and patients with elevated intraocular pressure who do not have glaucoma. SCODI also permits high resolution assessment of the retinal and choroidal layers, the presence of thickening associated with retinal edema, and of macular thickness measurement. Vitreo-retinal and vitreo-papillary relationships are displayed permitting surgical planning and assessment. INDICATIONS OF COVERAGE: SCODI is considered to be reasonable and necessary to: Diagnose early glaucoma and monitor glaucoma treatment Differentiate causes of other optic nerve disorders when a diagnosis is in doubt. Diagnose and manage the patient's condition when visual field results are insufficient; or when reliable visual field testing cannot be performed, due to visual, physical, mental, or age constraints. Differentiate when a discrepancy exists between the clinical appearance of the optic nerve and the visual fields Detect further loss of optic nerve or retinal nerve fiber layer changes in the presence of advanced optic nerve damage and advanced visual field loss Diagnose and manage medically and surgically retinal and neuro-ophthalmic diseases which involve changes in the optic nerve, subretinal and intraretinal changes, vitreo-retinal relationships and changes in the nerve fiber layer. Follow glaucoma suspects. LIMITATIONS OF COVERAGE: Absence of an indication Screening

Coding Information

Bill Type Codes: ^{back to top}

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.

Revenue Codes: ^{back to top}

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.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

92135 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, POSTERIOR SEGMENT, (EG, SCANNING LASER) WITH INTERPRETATION AND REPORT, UNILATERAL

ICD-9 Codes that Support Medical Necessity ^{back to top}

190.6	MALIGNANT NEOPLASM OF CHOROID
191.0 - 198.3	MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
224.6	BENIGN NEOPLASM OF CHOROID
225.0 - 239.7	BENIGN NEOPLASM OF BRAIN - NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM
360.11	SYMPATHETIC UVEITIS
360.21	PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA
360.30 - 360.34	HYPOTONY OF EYE UNSPECIFIED - FLAT ANTERIOR CHAMBER OF EYE
361.00 - 361.07	RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL
361.10	RETINOSCHISIS UNSPECIFIED
361.2	SEROUS RETINAL DETACH
361.81	TRACTION DETACH OF RETINA
362.01 - 362.06	BACKGROUND DIABETIC RETINOPATHY - SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY
362.07	DIABETIC MACULAR EDEMA
362.10 - 362.18	BACKGROUND RETINOPATHY UNSPECIFIED - RETINAL VASCULITIS
362.31 - 362.32	CENTRAL RETINAL ARTERY OCCLUSION - RETINAL ARTERIAL BRANCH OCCLUSION
362.35 - 362.37	CENTRAL RETINAL VEIN OCCLUSION - VENOUS ENGORGEMENT OF RETINA
362.40 - 362.43	RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM
362.50 - 362.77	MACULAR DEGENERATION (SENILE) OF RETINA UNSPECIFIED - RETINAL DYSTROPHIES PRIMARILY INVOLVING BRUCH'S MEMBRANE
362.81	RETINAL HEMORRHAGE
362.82	RETINAL EXUDATES AND DEPOSITS
362.83	RETINAL EDEMA
362.85	RETINAL NERVE FIBER BUNDLE DEFECTS
363.00 - 363.08	FOCAL CHORIORETINITIS UNSPECIFIED - FOCAL RETINITIS AND RETINOCHOROIDITIS PERIPHERAL
363.10 - 363.15	DISSEMINATED CHORIORETINITIS UNSPECIFIED - DISSEMINATED RETINITIS AND RETINOCHOROIDITIS PIGMENT EPITHELIOPATHY
363.20 - 363.35	CHORIORETINITIS UNSPECIFIED - DISSEMINATED SCARS OF RETINA
363.43	ANGIOID STREAKS OF CHOROID
363.61	CHOROIDAL HEMORRHAGE UNSPECIFIED
363.63	CHOROIDAL RUPTURE
363.70 - 363.72	CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH
364.22	GLAUCOMATOCYCLITIC CRISES
364.53	PIGMENTARY IRIS DEGENERATION
364.73	GONIOSYNECHIAE
364.74	ADHESIONS AND DISRUPTIONS OF PUPILLARY MEMBRANES
364.77	RECESSION OF CHAMBER ANGLE OF EYE
365.00 - 365.04	PREGLAUCOMA UNSPECIFIED - OCULAR HYPERTENSION
365.10 - 365.15	OPEN-ANGLE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA
365.20 - 365.24	PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA
365.31 - 365.32	CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE - CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE
365.41 - 365.44	GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES
365.51	PHACOLYTIC GLAUCOMA
365.52	PSEUDOEXFOLIATION GLAUCOMA
365.59	GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS
365.60 - 365.65	GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER - GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA
365.81 - 365.89	HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA
368.40 - 368.45	VISUAL FIELD DEFECT UNSPECIFIED - GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION
376.00 - 376.9	ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - UNSPECIFIED DISORDER OF ORBIT
377.00 - 377.03	PAPILLEDEMA UNSPECIFIED - PAPILLEDEMA ASSOCIATED WITH RETINAL DISORDER
377.04	FOSTER-KENNEDY SYNDROME
377.10	OPTIC ATROPHY UNSPECIFIED
377.14 - 377.16	GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC - HEREDITARY OPTIC ATROPHY
377.21	DRUSEN OF OPTIC DISC
377.22	CRATER-LIKE HOLES OF OPTIC DISC
377.23	COLOBOMA OF OPTIC DISC
377.24	PSEUDOPAPILLEDEMA
377.41 - 377.49	ISCHEMIC OPTIC NEUROPATHY - OTHER DISORDERS OF OPTIC NERVE
377.51 - 377.54	DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS - DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS
377.61 - 377.63	DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS - DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH INFLAMMATORY DISORDERS
377.9	UNSPECIFIED DISORDER OF OPTIC NERVE AND VISUAL PATHWAYS
379.11 - 379.19	SCLERAL ECTASIA - OTHER SCLERAL DISORDERS
379.21 - 379.29	VITREOUS DEGENERATION - OTHER DISORDERS OF VITREOUS
743.20 - 743.22	BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES
743.57 - 743.58	SPECIFIED CONGENITAL ANOMALIES OF OPTIC DISC - VASCULAR ANOMALIES CONGENITAL
743.59	OTHER CONGENITAL ANOMALIES OF POSTERIOR SEGMENT
854.00 - 854.09	INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED
921.3	CONTUSION OF EYEBALL

Diagnoses that Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

All ICD-9 Codes not listed under the “ICD-9 Codes That Support Medical Necessity” section of this policy will be denied.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

General Information

Documentation Requirements ^{back to top}

Indications for SCODI must be described in the medical record.

The primary diagnosis for SCODI, listed on the claim form, must support the medical necessity of the testing.

The diagnosis must be present for the procedure to be paid.

Medical records need not be submitted with the claim; however, the record must be furnished to the Contractor upon request or if services exceed the utilization guideline.

Complete ophthalmology examination describing the indications supporting medical necessity must be available in the patient's medical record. This description should include any evidence of the following for patients who are/have:

Glaucoma Suspect:

Anomalous appearing optic nerve

Intraocular pressure > 22mmHg as measured by applanation

Symmetric or vertically elongated cup enlargement, neural rim intact, cup to disc ratio > 0.4

Focal optic disk notch

Optic disk hemorrhage or history of optic disk hemorrhage

Glaucoma- No Glaucomatous Damage:

Medical or surgical therapy has been initiated to prevent visual field loss

Glaucoma- Mild Glaucomatous Damage:

Nasal step or small paracentral or arcuate scotoma

Mild constriction of visual field isopters

Glaucoma- Moderate glaucomatous damage:

Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio > 0.5, but <0.9

Definite focal notch with thinning of the neural rim

Definite glaucomatous visual field defect, e.g., arcuate or paracentral scotoma, nasal step, pencil wedge, or constriction of isopters.

Glaucoma- Advanced glaucomatous damage:

Severe generalized constriction of isopters (i.e., Goldmann 14e> 10 degrees of fixation)

Absolute visual field defects within 10 degrees of fixation

Severe generalized reduction of retinal sensitivity

Loss of central visual acuity, with temporal island remaining

Diffuse enlargement of optic nerve cup, with cup to disc ratio > 0.8

Wipe-out of all or a portion of the neural retinal rim

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

In the management of a glaucoma patient,when SCODI is rendered more frequently than once in a 6 month period,the claim may be reviewed on a post-payment basis.

In the management of a patient who is a glaucoma suspect, when SCODI is rendered more frequently than once in a twelve month period, the claim may be reviewed on a post-payment basis.

Sources of Information and Basis for Decision ^{back to top}

1. Carrier Advisory Committee Ophthalmology and Optometry Working Group
2. Other Carrier’s policies
3. Copyright 1998 CPT Physicians’ Current Procedural Terminology, American Medical Association.
4. Copyright 2002 CPT Physicians’ Current Procedural Terminology, American Medical Association.

Advisory Committee Meeting Notes ^{back to top}

The Ophthalmology Advisory Committee

Start Date of Comment Period ^{back to top}

06/13/2005

End Date of Comment Period ^{back to top}

07/27/2005

Start Date of Notice Period ^{back to top}

08/01/2005

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

R9
10/01/2007
ICD9CM Diagnosis codes 233.30-233.39 were inserted into existing range 225.0 through 239.7

R8
02/10/2006
Changed language under utilization guidelines on each bullet from "the claim will be reviewed on an individual consideration basis" to "the claim may be reviewed on a post-payment basis.

R7
09/15/2005
Added ICD9CM diagnosis codes 362.03-362.07

R6
06/13/2005
Under Indications of Coverage Section:

Removed language “with significant risk factors.”

Under Documentation Guidelines Section:

Removed: “or mild glaucomatous damage” related to glaucoma suspect /li>

Added: Glaucoma- No Glaucomatous Damage category

Added: Glaucoma- Mild Glaucomatous Damage category

Under the Documentation Guideline Section:

Added the following italicized language: Medical records need not be submitted with the claim; however, the record must be furnished to the Contractor upon request or if services exceed the utilization guideline.

Under Contractor's Determination Number Section

Removed: Contractor's Determination Number

Under Utilization Guideline Section

Added the following:

- In the management of a glaucoma patient,when SCODI is rendered more frequently than once in a 6 month period,the claim will be reviewed on an individual consideration basis. Documentation supporting medical necessity must be submitted with the claim.
- In the management of a patient who is a glaucoma suspect, when SCODI is rendered more frequently than once in a twelve month period, the claim will be reviewed on an individual consideration basis. Documentation supporting medical necessity must be submitted with the claim.

R5
02/02/2004
National Coverage Policy crosswalked to CMS Manual System (Internet Only Manual)

R4
01/23/2004
This LCD was converted from an LMRP on 01/23/2004
The LMRP description was added to the Indications and Limitations Section of the LCD

R-3
03/01/2003
Revised the description and the language in the indications and limitations of coverage 6th bullet to read “vitreo-retinal”Added the diagnosis code 363.61 to support medical necessity,

R-2
10/01/2002
Corrected truncated ICD-9 code 360.3 to 360.30: removed invalid ICD-9 code 377.25

R-1
03-01-2002
ADD ICD-9 code 377.04

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

11/10/2007 - The description for CPT/HCPCS code 92135 was changed in group 1

Reason for Change ^{back to top}

ICD9 Addition/Deletion

Last Reviewed On Date ^{back to top}

09/10/2007

Medicare Coverage Database

LCD for SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (SCODI) (L10804)