Ophthalmology Coding, Ophthalmology Practice Tips
Understanding CPT Code 92134 Reimbursement
The 92134 CPT code is reimbursed at a national Medicare rate averaging approximately $40 to $50 per session, whether one or both eyes are tested. This rate covers both technical and professional components if billed together and is described as ‘unilateral or bilateral’. You might be curious why there isn’t a difference in payment for one or two eyes – this is because the procedure inherently includes both without modifiers.
Key Factors Influencing Reimbursement
- Geographic Variations:
o Payments may fluctuate due to regional differences in Medicare Administrative Contractor (MAC) coverage. The local policies can adjust this amount slightly, so it’s worth checking what applies in your area.
- Annual Updates:
o The Medicare Physician Fee Schedule updates each year, potentially altering reimbursement amounts.
Billing Specifics for 92134
- Unilateral or Bilateral:
o The code is identified ‘unilateral or bilateral; retina’, which means you bill once per session even if both eyes are scanned. Avoid using separate line items with RT/LT or 50 modifiers.
- Modifier Use:
o Generally, modifiers aren’t needed unless you separate technical (-TC) and professional (-26) billing. However, if a repeat procedure occurs on the same day, a -76 modifier could apply.
- Frequency of Billing:
o Typically, Medicare allows this code up to 4 times a year. However, for patients with specific retinal conditions requiring frequent monitoring, more frequent billing might be permissible.
2025 Update: OCT Angiography
Starting January 1, 2025, a new code, 92137, covers Optical Coherence Tomography Angiography (OCTA) with a higher reimbursement rate. This arises from a need for increased resource utilization for these more complex services. For now, the traditional OCT falls under 92134.
Medical Necessity and Coverage
Coverage relies on medical necessity, proven by specific diagnosis codes like those for macular degeneration or glaucoma. Insurers’ requirements can vary, so always verify prior to billing.
Key Takeaways for Billing 92134
- The reimbursement average is $40–$50 per session in 2024–2025.
- Avoid separate billing for each eye; no bilateral modifiers are necessary.
- Check local guidelines for frequency limits and coverage.
- New OCTA services have separate code and billing starting 2025.
Always confirm current payer-specific guidelines and fee schedules to ensure accurate billing and reimbursement. Contact Eye Care Billing Consultants for more information.
