The first rule of coding is to know the answer to this question: Who is the payer? Mastering the unique policies of insurance payers and understanding each payer’s nuances will help pave the path to success. Variables to consider include medical necessity criteria, specific coverage type, and documentation requirements.

CMS and Medicare Administrative Contractors (MACs) publish local and national policies. Commercial, Medicaid, and Medicare Advantage plans either follow the rules of CMS or create their own. Staying informed and identifying the quirks of each unique policy for your most common procedures is recommended.

At a Glance

  • “Who is the payer?” is one of the most important questions one can ask in coding for retinal evaluations.
  • Knowing the differences among Medicare, Medicaid, Medicare Advantage, and commercial insurance policies is key to understanding why some claims may be processed or denied.

Here are a few questions from the mailbag that will improve your knowledge on payer policies.

Question: We received a claim denial. Are CPT codes 92134 (OCT) and 92201 or 92202 (extended ophthalmoscopy) bundled?

Discussion: The National Correct Coding Initiative (NCCI) bundles outlined in the Table show that these two codes are not bundled. To explore further, let’s ask ourselves: Who is the payer?

In this specific case, the physician practices in Vermont and the payer is Medicare. National Government Services (NGS), the MAC for that region, has published local coverage determination (LCD) L33567, which states:

When other ophthalmological tests (eg, fundus photography, fluorescein angiography, ultrasound, optical coherence tomography, etc.) have been performed, extended ophthalmoscopy will be denied as not medically necessary unless there was a reasonable medical exception that the multiple imaging services might provide additive (non-duplicate) information.

Answer: NGS will deny 92134 and 92201 or 92202 unless there is a reasonable medical exception supporting performing the two services on the same day.

Question: The testing services performed today were CPT code 92134 (OCT) for macular edema and 92250 (fundus photography) for choroidal neoplasm. Can these codes be billed on the same day given the separate diagnoses?

Discussion: NCCI bundles CPT codes 92134 and 92250 with indicator 1, which means unbundling may be allowed under certain circumstances (Table). Typically, this is allowed when a unique payer policy approves unbundling. Is that the case in this situation? Let’s return to our question: Who is the payer?

The question was submitted from a practice in Texas, and the payer is Medicare. The MAC for that region, Novitas, has published LCD L35038, which states:

Fundus photography and posterior segment SCODI [scanning computerized ophthalmic diagnostic imaging of the posterior segment] performed on the same eye on the same day are generally mutually exclusive of one another … . The provider is not precluded from performing both on the same eye on the same day when each service is necessary to evaluate and treat the patient. The medical record should clearly document the medical necessity of each service. Frequent reporting of these services together may trigger focused medical review.

Answer: Novitas will allow the unbundling of CPT codes 92134 and 92250 with the -59 modifier when medically necessary. Documentation should reflect the reason for the two tests the same day, and practices should be prepared for a focused medical review of these claims.

Question: A claim denial was received for CPT codes 67228-RT (panretinal photocoagulation) and 67028-RT (intravitreal injection). These two codes are not bundled. Why did the insurance carrier deny the claim?

Discussion: It is correct that 67228 and 67028 are not bundled under NCCI edits. In this instance, however, the payer is a commercial payer.

Answer: The descriptor for CPT code 67028 includes the language separate procedure. Although Medicare does not consider the separate procedure definition, many commercial payers recognize this distinction. Separate procedures can be billed if they are the only procedure provided during an encounter. As a result, commercial payers may deny CPT code 67028 billed the same day as other procedures, including, in this case, panretinal photocoagulation.

Current LCDs for each MAC can be explored at