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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use
this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and
owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be
construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for
such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to
government use. CPT® is a trademark of the American Medical Association.
01-92000-17
Original Effective Date: 04/17/00
Reviewed: 08/26/10
Revised: 09/15/10
Subject: Scanning Computerized Ophthalmic Diagnostic Imaging
THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE
OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE
RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT
BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL
COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.
Position Statement
Billing/Coding
Reimbursement
Other
References
Updates
Program Exceptions
Definitions
Related Guidelines
DESCRIPTION:
Glaucoma is a disease characterized by degeneration of the optic disc. Elevated intraocular pressure has long been thought to be the primary etiology,
but the relationship between intraocular pressure and optic nerve damage varies among patients, suggesting a multifactorial origin. For example, some
patients with clearly elevated intraocular pressure will show no damage to the optic nerve, while other patients with marginal or no pressure elevation
will nonetheless show optic nerve damage. The association between glaucoma and other vascular disorders, such as diabetes or hypertension,
suggests vascular factors may play a role in glaucoma. Specifically, it has been hypothesized that reductions in blood flow to the optic nerve may
contribute to the visual field defects associated with glaucoma.
Conventional management of the patient with glaucoma principally involves drug therapy to control elevated intraocular pressures and serial evaluation
of the optic nerve and the retinal fiber layer to detect glaucomatous change. Standard methods of evaluation include careful direct examination of the
optic nerve using the ophthalmoscope or stereophotography, or evaluation of visual fields. There has been interest in developing more objective,
reproducible techniques both to document optic nerve damage and to detect early changes in the optic nerve and nerve fiber layer (RNFL) before the
development of permanent visual field deficits.
Scanning Laser Glaucoma Tests (SLGT) include scanning laser polarimetry, optical coherence tomography (OCT), and confocal scanning laser
ophthalmoscopy. These testing devices use videographic digitized images to make quantitative topographic measurements of the optic nerve head and
surrounding retina. These tests allow for early detection of glaucoma damage to the nerve fiber layer or optic nerve of the eye, and follow up of patients
with glaucoma for signs of progression. Various studies compared the three technologies in patients with glaucoma.
Although these techniques differ, their objective is the same. Scanning laser glaucoma tests 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.
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Confocal Scanning Laser Ophthalmoscopy
Confocal scanning laser ophthalmoscopy (CSLO) is a laser-based image acquisition technique, which is intended to improve the
quality of the examination compared to standard ophthalmologic examination. A laser is scanned across the retina along with a
detector system. Only a single spot on the retina is illuminated at any time, resulting in a high-contrast image of great reproducibility
that can be used to estimate the thickness of the RNFL. In addition, this technique does not require maximal mydriasis, which may
be a problem in patients with glaucoma. The Heidelberg Retinal Tomograph is probably the most common example of this
technology.
Scanning Laser Polarimetry
The RNFL is birefringent, causing a change in the state of polarization of a laser beam as it passes. A 780-nm diode laser is used
to illuminate the optic nerve. The polarization state of the light emerging from the eye is then evaluated and correlated with RNFL
thickness. Unlike CSLO, scanning laser polarimetry (SLP) can directly measure the thickness of the RNFL. GDx® is a common
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example of a scanning laser polarimeter. GDx® contains a normative database and statistical software package to allow
comparison to age-matched normal subjects of the same ethnic origin. The advantages of this system are that images can be
obtained without pupil dilation, and evaluation can be done in about 10 minutes. Current instruments have added enhanced and
variable corneal compensation technology to account for corneal polarization.
Optical Coherence Tomography
Optical coherence tomography uses near-infrared light to provide direct cross-sectional measurement of the retinal nerve fiber
layer. The principals employed are similar to those used in B-mode ultrasound except light, not sound, is used to produce the 3dimensional images. The light source can be directed into the eye through a conventional slit-lamp biomicroscope and focused onto
the retina through a typical 78-diopter lens. This system requires dilation of the patient’s pupil. OCT is an example of this
technology.
POSITION STATEMENT:
Scanning computerized laser ophthalmic imaging (CPT code 92135; e.g., Confocal Laser Scanning, Optical Coherence Tomography, and Scanning
Laser Polarimetry) meets the definition of medical necessity to document the appearance of optic nerve in individuals with mild to moderate glaucoma
and glaucoma suspects. Glaucomatous damage is based on the following criteria:
Mild glaucomatous damage or glaucoma suspect as demonstrated by one (1) of the following:
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Intraocular pressure equal to or more than 22mmHg as measured by applanation;
Symmetric or vertically elongated cup enlargement, neural rim intact, cup/disc ratio more than 0.4;
Diffuse or focal narrowing or notching of disc rim, especially at the inferior or superior poles;
Diffuse or localized abnormalities of the retinal layer, especially at the inferior or superior poles;
Optic disc hemorrhage or history of optic disc hemorrhage;
Asymmetrical appearance of the optic disc or rim between fellow eyes to suggest loss of neural tissue;
Nasal step peripheral to 20 degrees or small paracentral or arcuate scotoma; OR
Mild constriction of visual field isopters.
Moderate glaucomatous damage as demonstrated by one (1) of the following:
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Enlarged optic cup with neural rim remaining but sloped or pale, cup to disc ratio more than 0.5 but less than 0.8;
Definite focal notch with thinning of the neural rim; OR
Definite glaucomatous visual field defect (e.g., arcuate defect, nasal step, paracentral scotoma, or general depression.
Scanning computerized laser ophthalmic imaging (CPT Code 92135) does not meet the definition of medical necessity for patients with advanced
glaucomatous damage who demonstrate any of the following:
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Diffuse enlargement of optic nerve cup, with cup to disc ratio more than 0.8;
Wipe-out of all or a portion of the neural retinal rim;
Severe generalized constriction of isopters (e.g., Goldmann I4e, less than 10 degrees of fixation);
Absolute visual field defects to within 10 degrees of fixation;
Severe generalized reduction of retinal sensitivity; OR
Loss of central visual acuity, with temporal island remaining.
For advanced glaucomatous damage, visual field testing should be performed. Late in the course of glaucoma, when the nerve fiber layer has been
extensively damaged, visual fieldtesting is more likely than scanning computerized ophthalmic diagnostic imaging to detect small changes, unless
visual field testing cannot be performed.
Scanning computerized laser ophthalmic imaging (CPT code 92135) is considered experimental or investigational when performed solely as a
screening method, for confirmation of a known diagnosis of glaucoma, or other indications not listed, as there is insufficient clinical evidence to support
the use of these tests for decision-making for those conditions.
Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral (CPT code 0187T) is considered
experimental or investigational as the available published clinical evidence does not support clinical value.
BILLING/CODING INFORMATION:
CPT Coding:
92135
Scanning computerized ophthalmic diagnostic imaging, posterior segment, (e.g., scanning laser) with interpretation and report,
unilateral
0187T
Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral (Investigational)
Code 92135 is considered a unilateral service. The provider should indicate which eye was treated with either a LT or RT modifier.
ICD-9 Diagnoses Codes That Support Medical Necessity:
115.02
Infection by Histoplasma capsulatum (retinitis)
190.6
Malignant neoplasm of eye, choroid
191.0 – 191.3
Malignant neoplasm of brain
224.6
Benign neoplasm of eye, choroid
225.0 – 225.9
Benign neoplasm of brain and other parts of nervous system
228.03
Hemangioma of retina
360.11
Sympathetic uveitis
360.21
Progressive high (degenerative) myopia
360.30 – 360.34 Hypotony of eye
361.00 – 361.07 Retinal detachment with retinal defect
361.10 – 361.19 Retinoschisis and retinal cysts
361.2
Serous retinal detachment
361.30 – 361.33 Retinal defects without detachment
361.81
Traction detachment of retina
362.01
Background diabetic retinopathy
362.02
Proliferative diabetic retinopathy
362.10 – 362.18 Other background retinopathy and retinal vascular changes
362.29
Other nondiabetic proliferative retinopathy
362.31
Central retinal artery occlusion
362.32
Retinal, arterial branch occlusion
362.35
Central retinal vein occlusion
362.36
Retinal, venous tributary (branch) occlusion
362.37
Retinal, venous engorgement
362.40 – 362.43 Separation of retinal layers
362.50 – 362.57 Degeneration of macula and posterior pole
362.60 – 362.66 Peripheral retinal degeneration
362.70 – 362.77 Hereditary retinal dystrophies
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 and focal retinochoroditis
363.10 – 363.15 Disseminated chorioretinitis and disseminated retinochoroiditis
363.20 – 363.22 Other and unspecified forms of chorioretinitis and retinochordoiditis
363.30 – 363.35 Chorioretinal; scars
363.40 – 363.43 Choroidal degenerations
363.54
Central choroidal atrophy, total
363.63
Chorodial rupture
363.70 – 363.72 Choroidal detachment
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
365.00 – 365.04 Borderline glaucoma [glaucoma suspect]
365.10 – 365.15 Open-angle glaucoma
365.20 – 365.24 Primary angle-closure glaucoma
365.31 – 365.32 Corticosteroid-induced glaucoma
365.41 – 365.44 Glaucoma associated with congenital anomalies, dystrophies, and systemic syndromes
365.51 – 365.59 Glaucoma associated with disorders of the lens
365.60 – 365.65 Glaucoma associated with other ocular disorders
365.81 – 365.89 Other specified forms of glaucoma
365.9
Unspecified glaucoma
368.40
Visual field defect, unspecified
368.41
Scotoma involving central area
368.42
Scotoma of blind spot area
368.43
Sector or arcuate defects
368.44
Other localized visual field defect
368.45
Generalized contraction or constriction
376.00 – 376.9
Disorders of the orbit
377.00 – 377.04 Papilledema
377.10 – 377.16 Optic atrophy
377.21 – 377.24 Other disorders of optic disc
377.30
Other disorders of optic disc
377.31
Optic papillitis
377.39
Other optic neuritis
377.41 – 377.49 Other disorders of the optic nerve
377.51 – 377.54 Disorders of opti chiasm
379.11 – 379.19 Other disorders of sclera
379.21 – 379.29 Disorders of vitreous body
743.20 – 743.22 Buphthalmos
743.57
Specified anomalies of optic disc
743.58
Vascular anomalies
743.59
Other congenital anomalies of posterior segment
921.3
Contusion of eyeball
REIMBURSEMENT INFORMATION:
Refer to section entitled POSITION STATEMENT.
PROGRAM EXCEPTIONS:
Federal Employee Program (FEP): Follow FEP guidelines.
State Account Organization (SAO): Follow SAO guidelines.
Medicare Advantage: Local Medicare considers anterior segment scanning ophthalmic diagnostic imaging (0187T) medically reasonable and
necessary for evaluation of specified forms of glaucoma and disorders of the cornea, iris and ciliary body.
DEFINITIONS:
Applanation: undue flatness, as of the cornea.
Arcuate: shaped like an arc.
Ciliary body: The structure in the eye that releases a transparent liquid (aqueous humor) inside the eye.
Cornea: The domed, transparent covering in the front of the eye that covers the iris and helps focus light on the retina.
Glaucoma: a group of eye diseases characterized by an increase in intraocular pressure which causes pathological changes in the optic disk and
defects in the field of vision.
Intraocular: within the eye.
Iris: The colored disc inside of the eye which controls the size of the pupil.
Isopter: a line depicting the area in the field of vision in which the visual acuity is the same.
Scotoma: an area of lost or depressed vision within the visual field, surrounded by an area of less depressed or of normal vision.
RELATED GUIDELINES:
None applicable
OTHER:
Other names used to report ophthalmologic techniques used to evaluate glaucoma:
Glaucoma Scope
Optic Nerve Head Analyzer
REFERENCES:
1. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-6911. Diabetic Retinopathy.
05/15/09.
2. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-6913. Idiopathic Macular Hole.
05/15/09.
3. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Guidelines Summary NGC-7151. Age-Related Macular
Degeneration. 09/01/09.
4. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma (Initial Evaluation). Summary of Benchmarks for Preferred
Practice Pattern Guidelines. November 2008.
5. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma (Follow-up Evaluation). Summary of Benchmarks for
Preferred Practice Pattern Guidelines. November 2008.
6. American Academy of Ophthalmology (AAO). Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation). Summary of
Benchmarks for Preferred Practice Pattern Guidelines. November 2008.
7. American Academy of Ophthalmology Ophthalmic Technology Assessment-Optic Nerve Head and Retinal Nerve Fiber Layer Analysis.
Accessed 09/19/03.
8. American Medical Association, CPT (current edition).
9. Blue Cross Blue Association Medical Policy Reference Manual. 9.03.06 – Ophthalmologic Techniques of Evaluating Glaucoma. 11/12/09.
10.
Blue Cross Blue Shield Association Technology Assessment-Retinal Nerve Fiber Layer Analysis for the Diagnosis and Management of
Glaucoma, Vol. 18, No. 17, 08/03.
11.
ECRI-Health Technology Assessment Information Service-Confocal Scanning Laser Ophthalmoscopy for the Diagnosis of Glaucoma,
Issue No. 35, 07/00.
12.
Florida Medicare Part B Local Coverage Determination. Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (L29276).
06/30/09.
13.
Greenfield et al. Role of Optic Nerve Imaging in Glaucoma Clinical Practice and Clinical Trials. Am J Ophthalmol. 2008 Apr; 145(4):598603. Epub 2008 Mar 4.
14.
Halkaidakis et al. Comparison of Optical Coherence Tomography and Scanning Laser Polarimetry in Glaucoma, Ocular Hypertension,
and Suspected Glaucoma. Ophthalmic Surg Laser Imaging. 2008 Mar-Apr: 39(2): 125-132.
15.
Hayes Directory of Technology of Assessments-Scanning Laser Polarimetry for Detection and Monitoring of Glaucoma, 06/02.
16.
Ortega et al. Discrimination between Glaucomatous and Nonglaucomatous Eyes Using Quantitative Imaging Devices and Subjective
Optic Nerve Head Assessment. Invest Ophthalmol Vis Sci. 2006 Aug;47(8): 3374-80
17.
Ortega et al. Effect of Glaucomatous Damage on Repeatability of Confocal Scanning Laser Ophthalmoscope, Scanning Laser
Polarimetry, and Optical Coherence Tomography. Invest Ophthalmol Vis Sci. 2007 Mar; 48(3): 1156-63.
18.
Shah et al. Combining Structural and Functional Testing for Detection of Glaucoma. Ophthalmology. 2006 Sep; 113(9): 1593-602.
19.
Vessani et al. Comparison of Quantitative Imaging Devices and Subjective Optic Nerve Head Assessment by General Ophthalmologists
to Differentiate Normal From Glaucomatous Eyes. J Glaucoma. 2009 Mar;18(3): 253-61.
COMMITTEE APPROVAL:
This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/26/10.
GUIDELINE UPDATE INFORMATION:
04/17/00
New MCG.
10/02/00
Various revisions.
12/31/00
Various revisions.
10/25/01
Reviewed investigational status – no changes.
08/15/02
Guidelines 01-92000-17 and 01-92000-19 combined. Optical Coherence Tomography added.
10/15/03
Annual review; reformatted description section, added additional ICD-9 diagnoses for Medicare & More that support
medical necessity, deleted the reimbursement statement for code 92135 and codes (92081, 92082, and 92083),
updated references. Added diagnoses 362.50 – 362.57 (Degeneration of macula and posterior pole).
10/16/03: Added statement for optical coherence tomography (OCT) for Medicare & More.
01/15/04
Deleted program exceptions for Medicare & More for 92135. Revised covered ICD-9 CM diagnoses for scanning
computerized ophthalmic diagnostic imaging (92135) to be consistent with local Medicare B Medical Policy.
07/15/04
Guideline archived, no longer scheduled for review.
02/15/10
Guideline revised, reformatted and returned to active status. Description section updated, ICD 9 coding revised, and
References updated.
09/15/10
Revision: MCG title changed; updated Billing/Coding Information section; updated Definitions section; added Program
Exception for Medicare Advantage; revised Reimbursement Information section, and formatting changes.
Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2010, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use
this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and
owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be
construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for
such use. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to
government use. CPT® is a trademark of the American Medical Association.
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Date Printed: October 1, 2010: 01:40 PM
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