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Disclaimers for Presentation Getting Paid for 1.All information was current at time it was prepared 2.Drawn from national policies, with links included in the presentation for your use Technology 3.Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations Rebecca Wartman, OD 4.Prepared and presented carefully to ensure the (Harvey Richman, OD) NSU Smoky Mountain Summer Conference information is accurate, current and relevant 5.No conflicts of interest exist for presenters- financial or July 2019 otherwise. However, Rebecca writes for Optometric Journals and consults with Care Centers OD PA.

Disclaimers for Presentation Disclaimers for Presentation 6. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services 7. AOA, NSU, its presenters, agents, and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained herein 8. The content of the COPE Accredited CE activity was prepared with assistance from Kara Webb (AOA Staff) and Doug Morrow OD

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Cornea and Topography Anterior Segment 92025 Computerized corneal topography, unilateral or bilateral with interpretation and report Detection of subtle corneal surface irregularity and

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Review Eye

Maps

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Ocular higher‐order wavefront maps Ocular higher‐order wavefront maps

3D view

Tangential and…

Settings

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Elevation maps Axial Curvature Measurments Various overlay and fit zone options

Topography color scales

Indications & Limitations of Coverage: Reasons For Denial: Post penetrating keratoplasty Non‐covered for refractive procedures Post kerato‐refractive complications Often billable privately for evaluations or Post op irregular astigmatism included in examination fee Corneal dystrophy, bullous keratopathy Complications of transplanted

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Corneal wavefront allows direct comparison of Corneal wavefront allows direct comparison of corneal and ocular wavefronts corneal and ocular wavefronts

Compare corneal with total WF

Corneal Wavefront Analysis The Future Currently, no separate code for Corneal Wavefront Analysis Cannot use Corneal Topography for this 0402T Collagen cross‐linking of cornea (including removal of the corneal 92499 possible but miscellaneous service often not covered and often require special report with claim epithelium and intraoperative pachymetry when performed) Consider using ABN to collect from patient

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Corneal Hysteresis Low Corneal Hysteresis 92145 • Optic nerve damage Corneal hysteresis determination, by air impulse stimulation, • Visual field loss unilateral or bilateral, • Functional progression of GLC with interpretation and report • Larger magnitude of IOP reduction No utilization guidelines or published LCDs • National Non‐facility Medicare Fee $17.66 Dynamic finding may increase with medications

Cornea’s ability to absorb and dissipate energy

0198T 92286 Measurement of ocular blood flow by repetitive Anterior segment imaging intraocular pressure sampling, with interpretation and report interpretation and report Specular microscopy and endothelial cell analysis Often not paid current since Category III Bilateral Service Consider using an ABN National Non‐facility Medicare fee= $39.64

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92286 Justified Corneal Slit lamp evidence of endothelial dystrophy (guttata) & Confocal corneal edema Microscopy Undergoing secondary implant Previous ocular surgery now requires Fitting with extended wear contact after ocular surgery

Limitations‐ Not eligible if only visual problem is cataract considered part of presurgical examination. Preoperative evaluation of refractive keratoplasty not covered

Corneal Confocal Microscopy Guidelines Examines unmyelinated corneal nerve fibers @ high magnification, using laser‐scanning CCM to image corneal sub‐ Visual fields sometimes used determine medical necessity basal nerve plexus Often performed with taped lids then untapped lids Can predict insipient peripheral neuropathy in Type 1 DM Repeated service should be submitted with CPT modifier (63% Sensitive; 74% Specific) 76 on a separate detail line Reduced Corneal NFL length & Corneal sensitivity = increased severity diabetic peripheral neuropathy Typically pay 1 field ‐2nd field often denied Previous studies demonstrate utility for CCM in other neuropathies External Photos now often used No Code ‐ 92499‐ Miscellaneous with ABN Review carrier LCD Not included in 92286

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New Blepharoplasty Guidelines CGS: Complaint ‐ Physical findings ‐ Visual fields and/or photos Blepharoplasty Photos Noridan: Complaint ‐ Physical finding ‐ Photos WPS: Complaint ‐ Physical findings ‐ Visual fields –Photos Novitas: Complaint – Physical findings ‐ Photos Palmetto: Complaint ‐ Physical findings –Photos NGS: Compliant‐Physical findings –Viesualfields and/or photos First Coast‐ Physicial findings‐ Visual fields‐Photos 7 Carriers with LCD for Blepharoplasty 3have eliminated Visual Fields requirement 2 list Visual Fields and/or Photos

External Ocular Photography 92285 Anterior Segment Photography Bilateral Code Check carrier for limitations or restrictions of coverage 92285 External ocular photography is covered when a special camera is used to obtain magnified photographs of lesions (e.g., the cornea, iris or lids) for purpose of following the patient's condition External ocular photography with interpretation Medical quality images may be of digital, Polaroid Macro 3 SLR or and report for documentation of medical progress equivalent (eg, close‐up photography, slit lamp photography, gonio‐photography, stereo‐photography) Photographs for purpose of documenting for medicolegal purposes or preauthorization (e.g., gross trauma, amount of Medicare Fees National Non‐Facility Fee $39.64 ptosis or redundant lid tissue) are not separately reimbursed ‐ not medically necessary 32

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Diagnostic CPT's Pupilometry Pachymetry: CPT 76514 Bilateral. Billable for Corneal Problems and Glaucoma. Requires Interpretation and Report.

Pupilometry Pupilometry

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Pupilometry June 21 2018

Pupilometry MGD Dysfunction CPT 0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral RVU=0 Local Carrier Priced if covered

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Ocular Surface MGD Imaging Interferomoter

CPT III CODES 0507T Near infrared dual imaging (ie, simultaneous 0330T Tear film Imaging reflective and transilluminated light) of unilateral or bilateral‐report meibomian glands, unilateral or bilateral, with interpretation and report 0207T Clear gland Again, CPT III codes typically not covered without specific w/ heat/intermittent pressure carrier guidance Consider using an ABN

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0514T Lens Autofluorescence

Intraoperative visual axis identification using patient fixation (List separately in addition to code for primary procedure) (Use 0514T in conjunction with 66982, 66984)

FDA Market Clearance 2013

Lens Autofluorescence Lens Autofluorescence Using Lens Fluorescence Biomicroscope calibrated with standards traceable to National Institute of Standards and Integral to General Ophthalmologic or E&M Now Technology (NIST): No LCD/ Medical Policy Type 2 DM Detection (via AGEs on lens) 92499 could be considered but not recommended Sensitivity = 67%, Specificity = 94% (Hemoglobin A1C: Sens.= 44%, Spec.= 79%) (Fasting Plasma Gluc.: Sens.=50%, Spec.= 95%)

Takes 6 secs, non‐invasive, doesn’t require fasting

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92072 Fitting of a contact lens for management of keratoconus, initial fitting. Question: For subsequent fittings, use either the 9921X or 9201X codes. At what point after the initial fitting of a

Report materials in addition to this code, using either 99070 keratoconus lens is a new lens (not a or the appropriate HCPCS Level II material code. replacement) billable with code 92072 due to the fact that the lens no longer fits the patient’s need?

Answer: Description of work for initial fittings includes the results of diagnostic tests done prior to contact lens fitting to assess the corneal Glaucoma ectasia, which and are used in concert with slit lamp examination to assess corneal shape and determine initial contact lens parameters (eg, diameter, base curve, and secondary curves). Lens designs can include corneal, scleral, hybrid, or piggyback systems. Keratometry, lid anatomy, tear film, and refraction are also performed and/or rechecked. If the lens need to be changed because it no longer fits the patient’s needs, the fitting of new lens is considered an initial fitting and should include all of the services noted above.

CPT Assistant September 2017

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Gonioscopy 92020 Anterior OCT Used to diagnose injury or disease in anterior chamber of eye, performed under local anesthetic due to necessity of placing specialized lens directly on the eye to obtain a clear image Bilateral Procedure Code Medicare National Non‐facility Fee: $28.11 LCD Utilization

92132 76513 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B‐scan or high resolution IMAGING, ANTERIOR SEGMENT, WITH INTERPRETATION AND biomicroscopy REPORT, UNILATERAL OR BILATERAL Two‐dimensional ultrasonic procedure used to determine detailed composition and contours of ocular and orbital structures for pathology No using 52 modifier or LT or RT modifier if only Employs water bath to allow ultrasound source to be held away from tissue Patient in supine position, eye cup is placed between lids, and filled with CPT codes not covered with SCODI: viscous solution High‐frequency ultrasound probe is placed within bath in proximity to 76512, 76514 patient's eye High resolution, high magnification, detailed images obtained of anterior National Medicare Non‐facilty Fee $32.07 segment structures Eye cup is removed, eye is rinsed, and examination performed to confirm no NOT corneal abrasion

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76513 or 92132 Visual Field Examinations CPT differentiates between these two 92081 Limited, unilateral or bilateral, with technologies interpretation and report; examination If water bath ultrasound is used, code 76513 92082 Intermediate, unilateral or bilateral, If OCT technology is used, code 92132 with interpretation and report Reference CPT Asst 7‐2013 92083 Extended, unilateral or bilateral, with National Medicare Non‐Facility Fee $100.19 vs. $32.07 interpretation and report

A ‐ Baseline visual fields B ‐ Glaucoma Hemifield Test Guided Progression Analysis Glaucoma Management C ‐ Current visual field D ‐ GPA / Deviation from Baseline (Event Analysis) B E ‐ GPA Alert A F –VFI plot: Visual Field Index Display of Trend (3‐5yrs) under current conditions F (Trend Analysis) G ‐ VFI Bar: Remaining useful vision H G H ‐ Rate of Progression / Significance

CED 5 9

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Guided Progression Analysis Serial Visual Field Overview

Change of baseline ‐ intuitive & quick operation Visual Field Overview

Serial Visual Field Overview Indications & Limitations of Coverage Necessary to establish diagnosis Monitor course for treatment Determine change in therapeutic plan

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MILD visual field abnormality (inner circle Indications & Limitations of = 10 degrees, outer circle = 20 degrees) Coverage 92081‐92082 medically necessary to diagnose and follow retinal disorders 92083 diagnosis or follow‐up of glaucoma or neurologic disease

MODERATE visual field abnormality (inner SEVERE visual field abnormality (inner circle = circle = 10 degrees, outer circle = 20 10 degrees, outer circle = 20 degrees) degrees)

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Coding Guidelines‐ VF Visual Field Technology

All services are considered bilateral 0378T Visual field assessment, with concurrent real ‐50 modifier not appropriate time data analysis and accessible data storage with patient initiated data transmitted to a remote ‐52 modifier if only doing one eye surveillance center for up to 30 days; review and ‐76 modifier if doing repeat procedure interpretation with report by a physician or other qualified health care professional

Scanning Laser Tests Versatile Multi‐Modality Imaging Confocal laser scanning (topography)

Optical Coherence tomography

Glaucoma

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Versatile Multi‐Modality Imaging Coding guidelines 92132‐3‐4 Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral or bilateral No using either a 52‐ LT or RT modifier if reduced CPT codes not covered with SCODI: 92225, 92226, 92250 59 modifier usage GA modifier usage with ABN

92133‐Glaucoma Indications Glaucoma Severity/Staging Scanning Computerized Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; Level Scanning Laser Frequency optic nerve Current frequency limitations for Scanning Laser for most regions: Technological improvements have rendered SCODI as valuable diagnostic tool in diagnosis and treatment of glaucoma. These improvements enable discernment of changes of nerve fiber even Mild or Suspect Glaucoma 1 Time per year in advanced cases of glaucoma. Moderate Glaucoma 2 Times per year Expected that only two exams/eye/year would be required to manage the patient who has glaucoma or is suspected of having Advanced or Severe Glaucoma NO Scanning laser but up to glaucoma. 4 Visual Fields / year

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Ganglion Cell Analysis Utilization Guidelines‐GLC Isolates Ganglion Cell Layer Although CMS guidelines state • Measures thickness for sum of GCL and IPL layers using data from Only two exams/eye/year are allowed for patient who has or is suspected Macular cube scans. of having glaucoma • RNFL distribution in the macula depends on individual anatomy, while Most LCD state once per year to follow pre‐glaucoma patients or those the GCL+IPL appears regular and elliptical for most normal individuals with “mild” stage Propriety Excludes RNFL One or two tests per year for patients with “moderate staging,” algorithms are followed with SLT or visual fields adapted for if both SLT and visual fields are used, only one of each tests specific anatomy, use “Advanced stage” field testing preferred by Medicare guidance GCL and IPL thickness

Ganglion Cell Analysis 0464T Key Elements 0464T Visual Evoked Potential,

• ThicknessDeviation Maps Map testing for glaucoma, with • ShowSector thicknessa maps - interpretation and report measurementscomparisondivide the elliptical of of the GCL + IPL in the GCLannulus + IPL of the (For visual evoked potential screening for visual • 6mmThicknessThickness by 6mm Maptable cube into thickness to acuity, use 0333T) andnormativeShows6 regions: contains average data. 3 equallyan and ellipticalminimumsized sectors annulus thickness in the centeredwithinsuperior the aboutregion elliptical the and • Horizontal and fovea.annulus.3 equally sized Vertical B-scans. sectors in the inferior region. Values are compared to normative data.

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Macular Diseases All relevant information on 1 screen First visit Prior visit Todays visit

Screen Layout

1 glance to see change Navigate multiple visits all at once

Visualization of change Synchronized navigation

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HD Line raster in MultiMode Navigator Completes the combined information between Versatile Multi‐Modality Imaging OCT data and fundus images

RPE Detachment

Versatile Multi‐Modality Imaging Versatile Multi‐Modality Imaging

Proliferative Diabetic Retinopathy

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Versatile Multi‐Modality Imaging Diagnostic Insight

Greater Diagnostic Insight 92134‐Scanning Computerized Ophthalmic Dagnostic Review Integrated Images and Registered OCT Scans Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Retinal disorders are most common causes of severe and permanent vision loss. These technologies are valuable tools for evaluation and treatment of patients with retinal disease, especially macular abnormalities. These imaging techniques are useful tools to measure effectiveness of therapy, and in determining need for ongoing therapy, or safety of cessation of therapy.

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92134‐Scanning Computerize Ophthalmic Diagnostic Imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina Retinal Imaging CPT III Code Utilization Guidelines‐AMD/DR Only one exam/eye/2 months is allowed for the patient whose primary ophthalmological diagnosis is related to a retinal disease 0380T Computer‐aided animation +

One exam/eye/month is allowed for the patient who is undergoing analysis of time series retinal images active treatment for macular degeneration or diabetic retinopathy for the monitoring of disease progression, unilateral or bilateral, with Glaucoma? interpretation and report

Fundus Autofluorescence (FAF) Potential info health & function of entire retina Photoreceptors contain light‐sensing molecules susceptible to damage/x‐linking, & shed their damaged outer segments RPE phagocytize the segments & molecules stored in liposomes, forming lipofuscin (LF) Disease states & oxidative damage =  LF Hyper‐fluorescence = excess LF accumulation Hypo‐fluorescence = RPE cells die/are absent

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LASER Speckle Flowgraphy Angiography software‐OCTA Noninvasive way to assess ocular blood flow CRVO study completed Non‐invasive, dyeless

Hi‐res, 3‐D visualization of retinal vasculature

Images motion of scattering particles such as RBCs using sequential OCT x‐sectional scans .

92250: Photography

Fundus photography with interpretation and report Document abnormalities Check carrier’s medical policy for limitations or Bilateral Code restrictions of coverage

Obtain filing requirements from carrier for bilateral or multiple procedures

99 100

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92250 Utilization Guidelines Wide Field Retinal Screening

Some carriers state it is not medically necessary to repeat fundus photography more often than every 2 years for follow‐up of stable glaucoma. Repeat photographs for retinopathy are rarely necessary.

S9886 Macular Pigment Densitometers Not Medically Necessary Service Patient is aware not medically necessary No Current LCD Screenings are not covered in most cases No Current Defined Code Studies Inconclusive

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MPOD Assessment‐ Heterochromic Flicker 92081? Photometry‐92081?

Preferential Hyperacuity 0469T Perimeter • Retinal polarization scan, ocular screening with on‐site automated results, bilateral • Retinal Birefringence scanners (RBS) • hand held instruments • measure the changes in the polarization of light • detect eye misalignment or strabismus • No LCD • Medical Policy E/I/U Discontinued 92082‐?

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Ganglion Cell Analysis: Use 92134 Isolates Ganglion Cell Layer Fundus Photography & SCODI • Measures thickness for sum of GCL and IPL layers using data from Macular cube scans. • RNFL distribution in macula depends on individual anatomy, while Continued confusion on billing photography and SCODI on GCL+IPL appears regular and elliptical for most normal individuals same date of service Propriety Excludes RNFL algorithms are They are “mutually exclusive” as defined by current NCCI adapted for specific Mutually exclusive is defined as “procedures that cannot anatomy, use reasonably be performed at the same anatomic site or same GCL and IPL encounter.” thickness

Fundus Photography & SCODI National Correct Coding Initiative (NCCI) • Developed with RBRVS‐ 2003 • Insures proper Medicare payments There has been no specific document defining when you (Resource Based Relative Value System) can use 92133 and 92134 with 92250 • Identify pairs of services not billed together (same physician for same patient on same day) This means there is no official CMS guidance on using • Component element edits o 92012 and 92014 “mutually exclusive” codes on the same date of service. • Medically Unlikely Edits (MUE) policy manual o 92133 or 92134 and 92250 but MAY use ‐59 modifier o 92133 and 92134 may NOT be used together even with ‐59 modifier

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NCCI Edits NCCI Edits Relevant to • MUE together, column 1 code is paid Fundus photography (CPT code 92250) and • MUE MAY be allow together scanning ophthalmic computerized diagnostic o 0 not allowed imaging (e.g., CPT codes 92132, 92133, 92134) are o 1 allowed generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. o 9 non‐applicable However, there are a limited number of clinical conditions where both o If clinical circumstances justify appending a modifier techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier 59 to to column 2 code of code pair, payment for both CPT code 92250. (CPT code 92135 was deleted January 1, 2011.) codes may be allowed CPT code 92071 (fitting of contact lens for treatment of ocular • MUST READ AND UNDERSTAND WHAT CAN BE surface disease) should not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a DONE TOGETHER AND WHEN procedure on the cornea. • Cannot use a modifier just to get paid

Modifier 59 Definition Modifier 59 History Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under Most widely used modifier according to the Centers the circumstances for Medicare & Medicaid Services (CMS) Modifier 59 should not be used to bypass a Procedure to Associated with considerable abuse Procedure (PTP) edit unless the proper criteria for use of the modifier are met. High levels of manual audit Documentation in the medical record must satisfy the criteria Triggers reviews and appeals required by any NCCI (National Correct Coding Initiative) associated modifier that is used. Results in civil fraud and abuse cases

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Modifier 59 New CMS Guidance Clinical Decision

Treatment of posterior segment structures in the We know that using modifier 59 has potential to trigger audits eye constitutes treatment of a single anatomic site. (See example 5‐Modifier 59) NCCI policy statement seems to give provider some wiggle room to use ‐59 modifier Modifier 59 should not be used if both procedures are performed during the same operative session Providers need to use caution if choose to use modifier 59 because the retina and choroid are contiguous Coding Experts recommend that scans be performed on structures of the same organ different visits to avoid potential for audits.

New Modifiers Further Defining Modifier 59 Changes Modifier 59 Since January 5, 2015 ‐ new X code modifiers X modifiers meant to define subsets of Modifier 59 Intended to more clearly define “Distinct Procedural Service” X modifiers provide more precise coding options Rules for use have not been written CMS acknowledges that increased education is needed CMS only modifiers – CPT manual has not been changed

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New Modifiers –X(EPSU) Modifiers New Modifiers –X(EPSU) Modifiers

XE Separate Encounter: XS  Separate Structure: Service that is distinct because it Service that is distinct because it was occurred during a separate encounter performed on a separate organ/structure

New Modifiers –X(EPSU) Modifiers New Modifiers –X(EPSU) Modifiers

XP Separate Practitioner: XU Unusual Non‐Overlapping Service: Service that is distinct because it was Use of a service that is distinct because it performed by a different practitioner does not overlap usual components of the main service.

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New Modifiers ‐ X(EPSU) Modifiers Visual Evoked Potential ‐ VEP 95930 UPDATE 2018 CMS continues to recognize Modifier 59 Visual evoked potential (VEP) checkerboard or flash testing, Instructions state that 59 should not be used when central nervous system except glaucoma, with interpretation a more descriptive modifier is available and report Providers should not use modifier 59 and a new X Bilateral Code modifier together for the same code General Supervision Special Training? Utilization Guidelines Carrier Dependent

0464T 0333T Visual Evoked Potential, testing for glaucoma, with interpretation and report May NOT use any other VEP code with glaucoma diagnosis

NEW CODE

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92275‐ERG 92273 (new 2019)

Electroretinography with interpretation and report (ERG), with interpretation and Bilateral Code report ; full field (ie, ffERG, flash ERG, Ganzfeld ERG) LCDs Changing Most TPP experimental except for plaquenil Not for EOMs Full field (flash and flicker) (92273) for a global response of photoreceptors of the retina

92274 (new 2019) 0509T (new 2019)

Electroretinography (ERG) with interpretation Electroretinography (ERG) with and Report; multifocal (mfERG) interpretation and report, pattern (PERG) Multifocal (92274) for photoreceptors in multiple separate locations in the retina, including the macula

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YOU SURVIVED Questions?

Thank You!

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