News from the AOA's Blog

Cost-cutting” and “technological innovation” have both emerged as key concepts in health care. However, a growing controversy over the assignment of new billing codes for laser retinal scanning illustrates how two important movements to improve the nation’s health care system can ironically clash—to the detriment of patients—when health policymakers aren’t careful, according to the AOA Advocacy Group.

With laser retinal scanning widely regarded to be among the most important new diagnostic eye care techniques to emerge over recent years, the AOA and other eye care practitioner organizations are fighting recent decisions that will effectively slow the growth of diagnostic imaging, a goal of Congress and the U.S. Centers for Medicare & Medicaid Services (CMS).

As previously reported in AOA News, the Current Procedural Terminology (CPT) coding system recently deleted CPT Code 92135 for computerized ophthalmic diagnostic imaging (e.g., laser scanning). It was replaced by two codes: 92133 and 92134. CPT 92135 indicated the procedure is unilateral, meaning the practitioner could bill for each eye on which the procedure was performed.

The new codes are bilateral, meaning practitioners are entitled to only one payment even if they provide the procedure on both eyes.

Reimbursement under Medicare for the new coding reflects the slightly higher physician work involved in scanning two eyes instead of one, but overall the doctor will be paid only about 50 percent as much if both eyes are scanned. (See “Year-end potpourri… retinal imaging codes change dramatically for 2011 and so many long-term Medicare fees,” AOA News, January 2011.)

Introduced two decades ago, laser scanning [i.e., ocular coherence tomography (OCT) and scanning laser ophthalmoscopy (SLO)] provides real-time, two-dimensional, in vivo depiction of the eye. It has become widely recognized as a valuable tool for the early diagnosis and monitoring of retinal of glaucoma, macular degeneration, diabetic retinopathy other retinal disorders. The technology has come into widespread use just as instances of those conditions are increasing, due to the aging of the U.S. population, a documented epidemic of diabetes and other factors.

Many eye care practitioners have been implementing laser retinal scanning technology in their practices, despite the often substantial cost. Primary care and endocrinology practices now routinely refer diabetes patients for annual retinal scans, according to the American Diabetes Association.

Retinal scanning reported to Medicare with CPT 92135 increased 135.5 percent over the past five year (reaching some 7,333,181 procedures in 2009) – a greater increase than for nearly all of the thousands of codes paid under the Medicare physician fee schedule.

o many patient advocates that indicates an important technological advance is being made widely available in a timely manner to provide cost-effective, preventive care for serious and increasingly common health conditions. However, amid concern over abuses in some other fields of care – and particularly about overutilization of diagnostic imaging – health plan administrators may see potential warning signs.

Laser scanning and other procedures for AMD were included in “Volume Growth in Medicare: An Investigation of Ten Physicians’ Services,” a December 2008 HHS report on the increasing costs associated with some Medicare-covered services.