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Young Ophthalmologists
Testing Before Cataract Surgery: When to Use OCT

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The American Academy of Ophthalmic Executives (AAOE) receives many coding questions concerning cataract surgery. One in particular caught our eye. It involved the use of an optical coherence tomography (OCT) on diabetic and age-related macular degeneration (AMD) patients prior to cataract surgery, to investigate and discriminate the cause of vision loss.

undefinedThis application of OCT is considered “screening” and not allowable by Medicare, unless something in the exam or history suggests an indication for the test, such as poor near vision or suspected maculopathy based on examination of the posterior pole.

Therefore, OCT is not part of a routine pre-op cataract evaluation, although there are circumstances under which it might be warranted. For instance, an OCT would be indicated in evaluating a macular problem that may coexist with a cataract. Such indications include suspicious findings in the history and exam that would point to a new change in the macula, not routine evaluation. Thus, it is medically indicated to obtain an OCT for a patient with both a cataract and AMD or diabetic retinopathy when retinal thickening is suspected to help determine the relative contribution of each disease to the visual impairment.

In these cases, it is advised (and possibly required) that the medical necessity be clearly documented in the patient’s chart and that the OCT be linked with the macular diagnosis and not with the cataract diagnosis when submitting for reimbursement.

However, whether cataract surgery is planned or not, if there is no diabetic retinopathy, or if AMD or diabetes is present with no suspicion of retinal thickening, there is no indication for OCT. In the absence of a clear indication, the surgeon may do the test “for his/her own peace of mind,” but it would not be billable. Therefore, if the OCT is considered a “routine pre-op cataract test,” it would not be covered. Rather, it is part of the medical evaluation of the patient prior to the decision for surgery.

Bottom line, the physician actually has to think about and document the indications for the test.

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About the author: This story was adapted from an article that originally appeared in the October 2008 issue of the AAOE’s Coding Bulletin.