SUPERCEDED LCD: Centers for Medicare & Medicaid Services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 12/05/2008

Revision Ending Date ^{back to top}
04/30/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) is a non-invasive, non-contact imaging technique. SCODI produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment disease. Posterior segment 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. Anterior segment SCODI is used in the evaluation and treatment planning of diseases affecting the cornea, iris, and other anterior chamber structures. The procedure also may be used to provide additional information during the planning and follow-up for corneal, iris, and cataract surgeries. INDICATIONS OF COVERAGE: Posterior Segment optical coherence tomography (OCT) 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. Anterior segment OCT is considered to be reasonable and necessary to: Evaluate narrow angle, suspected narrow angle, mixed narrow and open angle glaucoma, and angle recession as all determined by gonioscopy Determine the proper intraocular lens for a patient who has had prior refractive surgery and now requires cataract extraction Evaluate Iris tumor Evaluate corneal edema or opacity that precludes visualization or study of the anterior chamber Calculate lens power for cataract patients who have undergone prior refractive surgery. (Reimbursement will only be made for the cataract codes as long as additional documentation is available in the patient record of the prior refractive procedure. Reimbursement will not be made in addition to A-scan or IOL master.) Evaluate and plan treatment for patients with diseases affecting the cornea, iris, lens and other anterior segment structures. Provide additional information during the planning and follow-up for corneal, iris, cataract, glaucoma and other anterior segment surgeries. 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
0187T	SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND REPORT, UNILATERAL

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

The following ICD9CM Diagnoses codes in Group 1 are used in conjunction with 92135 only

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

The following ICD9CM Diagnoses codes in Group 2 are used in conjunction with 0187T only

190.0	MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID
190.3	MALIGNANT NEOPLASM OF CONJUNCTIVA
190.4	MALIGNANT NEOPLASM OF CORNEA
190.6	MALIGNANT NEOPLASM OF CHOROID
190.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE
224.0	BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID
224.3	BENIGN NEOPLASM OF CONJUNCTIVA
224.4	BENIGN NEOPLASM OF CORNEA
224.6	BENIGN NEOPLASM OF CHOROID
224.8	BENIGN NEOPLASM OF OTHER SPECIFIED PARTS OF EYE
360.51	FOREIGN BODY MAGNETIC IN ANTERIOR CHAMBER OF EYE
360.61	FOREIGN BODY IN ANTERIOR CHAMBER
364.51	ESSENTIAL OR PROGRESSIVE IRIS ATROPHY
364.52	IRIDOSCHISIS
364.53	PIGMENTARY IRIS DEGENERATION
364.54	DEGENERATION OF PUPILLARY MARGIN
364.55	MIOTIC CYSTS OF PUPILLARY MARGIN
364.56	DEGENERATIVE CHANGES OF CHAMBER ANGLE
364.57	DEGENERATIVE CHANGES OF CILIARY BODY
364.59	OTHER IRIS ATROPHY
364.60	IDIOPATHIC CYSTS OF IRIS AND CILIARY BODY
364.61	IMPLANTATION CYSTS OF IRIS AND CILIARY BODY
364.62	EXUDATIVE CYSTS OF IRIS OR ANTERIOR CHAMBER
364.63	PRIMARY CYST OF PARS PLANA
364.64	EXUDATIVE CYST OF PARS PLANA
364.70	ADHESIONS OF IRIS UNSPECIFIED
364.71	POSTERIOR SYNECHIAE OF IRIS
364.72	ANTERIOR SYNECHIAE OF IRIS
364.73	GONIOSYNECHIAE
364.74	ADHESIONS AND DISRUPTIONS OF PUPILLARY MEMBRANES
364.75	PUPILLARY ABNORMALITIES
364.76	IRIDODIALYSIS
364.77	RECESSION OF CHAMBER ANGLE OF EYE
364.81	FLOPPY IRIS SYNDROME
364.82	PLATEAU IRIS SYNDROME
364.89	OTHER DISORDERS OF IRIS AND CILIARY BODY
365.02	ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA
365.20 - 365.89	PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - OTHER SPECIFIED GLAUCOMA
366.16	SENILE NUCLEAR SCLEROSIS
370.00 - 370.07	CORNEAL ULCER UNSPECIFIED - MOOREN'S ULCER
371.00 - 371.05	CORNEAL OPACITY UNSPECIFIED - PHTHISICAL CORNEA
371.20 - 371.24	CORNEAL EDEMA UNSPECIFIED - CORNEAL EDEMA DUE TO WEARING OF CONTACT LENSES
371.50	HEREDITARY CORNEAL DYSTROPHY UNSPECIFIED
371.57	ENDOTHELIAL CORNEAL DYSTROPHY
371.71	CORNEAL ECTASIA
371.72	DESCEMETOCELE
371.73	CORNEAL STAPHYLOMA
372.40 - 372.45	PTERYGIUM UNSPECIFIED - RECURRENT PTERYGIUM
379.31	APHAKIA
379.32	SUBLUXATION OF LENS
379.33	ANTERIOR DISLOCATION OF LENS
379.39	OTHER DISORDERS OF LENS
996.51	MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT
996.53	MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS
996.69	INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT

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}

Posterior Segment Guidelines

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.

Anterior Segment Guidelines

In the management of the patient who has one of the diagnoses listed in Group 2 above, the rendering of SCODI is limited to once in a 12 month period. 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 12/5/2008

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}

R11

Revision History Explanation ^{back to top}

R11
12/05/2008
Expanded coverage of SCODI to include anterior segment with associated diagnosis codes, based on recommendation from the American Society of Cataract and Refractive Surgery and the New England Ophthalmology Society.

R10
10/01/2008
ICD9CM diagnosis code 238.77 was inserted into existing range.

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

08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update.

Reason for Change ^{back to top}

Coverage Change (actual change in medical parameters)
HCPCS Addition/Deletion
ICD9 Addition/Deletion

Last Reviewed On Date ^{back to top}

12/05/2008

Medicare Coverage Database

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