92134

🩺 CPT Code 92134: Documentation & Billing Guide

Ophthalmic diagnostic imaging of the posterior segment with interpretation and report, unilateral or bilateral; retina

Short Definition

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

Long Definition

CPT code 92134 describes computerized ophthalmic diagnostic imaging of the posterior segment of the eye, specifically focusing on the retina, using optical coherence tomography (OCT) technology. This non-invasive imaging technique provides high-resolution cross-sectional images of the retinal layers, allowing detailed visualization of retinal architecture including all ten layers of the neurosensory retina, the retinal pigment epithelium, and the underlying choroid.

The procedure is primarily used to diagnose and monitor macular diseases such as macular degeneration, diabetic macular edema, macular holes, epiretinal membranes, and other retinal pathologies. The code includes image acquisition using spectral-domain or swept-source OCT technology, physician interpretation of the images, and a written report documenting findings.

The service may be performed unilaterally or bilaterally, with one unit billed regardless of whether one or both eyes are imaged. This code specifically focuses on the retina and macula, and cannot be billed in conjunction with CPT 92133 (optic nerve OCT) at the same encounter, as they are mutually exclusive per CPT guidelines.

Area of Body

Posterior segment of the eye - retina and macula, specifically:

• Neurosensory retina (all ten layers from internal limiting membrane to photoreceptors)
• Retinal pigment epithelium (RPE)
• Bruch’s membrane
• Choroid (underlying vascular layer)
• Macula (central retina responsible for detailed central vision)
  • Fovea (central depression of macula)
  • Foveal avascular zone
  • Parafoveal region
  • Perifoveal region
• Retinal thickness measurements
• Intraretinal fluid compartments
• Subretinal space
• Sub-RPE space

Structures Visualized:

• Inner retinal layers (nerve fiber layer, ganglion cell layer, inner plexiform layer, inner nuclear layer)
• Outer retinal layers (outer plexiform layer, outer nuclear layer, external limiting membrane, photoreceptor layer)
• RPE-Bruch’s membrane complex
• Choroidal thickness and structure
• Vitreomacular interface

Service Components

Included Services:

• Image acquisition of retinal structures using OCT technology
• Multiple scan patterns (line scans, raster scans, radial scans, 3D cube scans)
• Technical component: Equipment operation, image capture, quality assessment, image optimization
• Professional component: Physician interpretation and report generation
• Written report documenting findings and measurements
• Bilateral imaging when performed (both eyes included in single unit)
• Quantitative measurements:
  • Central subfield thickness
  • Central 1mm thickness
  • Macular volume
  • Retinal thickness in ETDRS zones
  • Sectoral thickness measurements
• Qualitative assessment:
  • Retinal layer architecture
  • Presence of fluid (intraretinal, subretinal, sub-RPE)
  • Structural abnormalities
  • Comparison to normative database when applicable
• Comparison to prior examinations when available
• Color-coded thickness maps
• Image manipulation for optimal visualization

Excludes:

• Optic nerve OCT imaging (use 92133 - CANNOT bill together same encounter)
• Anterior segment OCT (use 92132)
• OCT angiography of retina (use 92137 - CANNOT bill together same encounter)
• Fundus photography alone (92250 - may be separately billable but check NCCI)
• Extended ophthalmoscopy (92225-92226)
• Fluorescein angiography (92235)
• Indocyanine green angiography (92240)
• Electrophysiologic testing (92273-92274)
• Ultrasound of eye (76510-76529)

Includes:

• Assessment of macular thickness and morphology
• Detection and quantification of macular edema
• Identification of intraretinal and subretinal fluid
• Evaluation of vitreomacular interface abnormalities
• Assessment of retinal layer disruption
• Choroidal thickness measurement
• Drusen visualization and measurement
• Retinal pigment epithelium abnormalities

RVU Information

Work RVU (wRVU): 0.52
Facility Total RVU: Approximately 0.80
Non-Facility Total RVU: Approximately 1.39
Global Days: XXX (diagnostic test, no global period)
Medicare Status: Active/Payable
2026 Medicare National Average: Approximately $45-48 (varies by locality)

RVU Notes:

• RVUs for OCT codes were revised and reduced in 2025
• Prior to 2025, total RVU was approximately 1.53
• Code 92134 is designated as Designated Health Service (DHS) under Stark Law as of 2025
• Same work RVU as 92133 (optic nerve OCT): 0.52 wRVU

RVU Comparison:

• 92132 (anterior segment OCT): 0.45 wRVU
• 92133 (optic nerve OCT): 0.52 wRVU
• 92134 (retina OCT): 0.52 wRVU ◄ Current code
• 92137 (retina OCT with angiography): 0.69 wRVU

HCC Status

Not Applicable - HCC coding applies only to ICD-10 diagnosis codes, not CPT procedure codes. However, retinal diagnoses documented during interpretation may map to HCC categories for diabetic retinopathy (HCC 122) and should be coded accurately.

Assistant Surgeon Status

Assistant Payable: Not Applicable

CPT 92134 is a diagnostic imaging service, not a surgical procedure. The concept of assistant surgeon does not apply to diagnostic testing services. Assistant surgeon modifiers (80, 81, 82, AS) are never used with diagnostic imaging codes.

Common Modifiers

Modifier	Description	Usage Frequency	Application	Notes
-26	Professional component only	Moderate	Interpretation without equipment ownership	Physician reads study performed elsewhere
-TC	Technical component only	Moderate	Image acquisition without interpretation	Facility bills for equipment/staff
-59	Distinct procedural service	Low	Rarely needed for 92134	May be required by some payers with certain procedures
-76	Repeat procedure by same physician	Low	Medically necessary repeat same day	Quality issues, patient repositioning needed
-77	Repeat procedure by different physician	Rare	Different provider repeats study	Unusual circumstance
-52	Reduced services	Rare	Incomplete study	Poor image quality, patient unable to complete
-RT	Right side	Not standard	Generally not used	Code includes bilateral
-LT	Left side	Not standard	Generally not used	Code includes bilateral
-GY	Statutorily excluded	Low	Non-covered by Medicare	Screening without medical necessity
-GA	Waiver of liability on file	Low	ABN obtained	When coverage uncertain
-GZ	Expected denial	Low	Service expected to deny	ABN not obtained

Critical Modifier Notes:

Modifier 26 and TC:

• Used to split global service into components
• Global (no modifier): Both technical and professional = full payment
• Modifier 26 (professional): Interpretation only = approximately 40% of total
• Modifier TC (technical): Image acquisition only = approximately 60% of total
• Common in hospital settings where facility owns equipment (bills TC) and physician interprets (bills 26)

Do NOT Use:

• Modifier 50 (bilateral): OCT retina codes are per-encounter, not per-eye
• Modifiers RT/LT: Not standard for 92134; code includes bilateral when performed
• Modifier 51 (multiple procedures): Automatically applied by payers, don’t append manually

Common Associated CPT Codes

CPT Code	Description	Relationship to 92134	Billing Considerations
92002-92014	Eye examination codes	Same encounter typical	Commonly billed together
92133	OCT optic nerve	MUTUALLY EXCLUSIVE same encounter	Cannot bill both 92133 and 92134 same day
92137	OCT retina with angiography	Alternative/more extensive	MUTUALLY EXCLUSIVE with 92134 same day
92132	OCT anterior segment	Can bill together	Different anatomic area, separately payable
92250	Fundus photography	May be bundled	Check NCCI; some payers bundle
92235	Fluorescein angiography	Commonly associated	Separately billable, different modality
92240	Indocyanine green angiography	May be associated	Separately billable
92081-92083	Visual field testing	May be associated	Separately billable
67028	Intravitreal injection	Commonly associated	OCT monitors treatment response
67210	Laser photocoagulation	May be associated	OCT for diagnosis/follow-up
67228	Laser for retinal disease	May be associated	Pre/post-treatment imaging
0621T	Trabeculostomy procedures	May be combined	Different anatomic focus

Common Combinations:

Retina Exam with OCT:

• 92012 or 92014 (examination)
• 92134 (retina OCT)
• Very common pairing for macular disease monitoring

OCT with Injection Therapy:

• 92012-25 or 92014-25 (exam with modifier 25)
• 92134 (OCT to assess treatment response)
• 67028 (intravitreal injection anti-VEGF)
• Common for wet AMD, diabetic macular edema

Cannot Bill Together Same Encounter:

• 92134 + 92133 (retina OCT and optic nerve OCT are mutually exclusive)
• 92134 + 92137 (retina OCT and retina OCT-angiography are mutually exclusive)
• Must choose which posterior segment OCT code is most appropriate

Code Tree/Hierarchy

CPT Manual Section: Medicine (90000-99999)
Subsection: Ophthalmology (92002-92499)
Major Category: Special Ophthalmological Services (92018-92499)
Subcategory: Other Specialized Services (92065-92145)
Service Type: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

OCT Code Family Structure:

Scanning Computerized Ophthalmic Diagnostic Imaging (92132-92134, 92137)
├── Anterior Segment
│   └── 92132 - OCT anterior segment
│
└── Posterior Segment (MUTUALLY EXCLUSIVE SAME ENCOUNTER)
    ├── 92133 - OCT optic nerve
    ├── 92134 - OCT retina ◄ Current Code
    └── 92137 - OCT retina with optical coherence angiography (OCTA)

CRITICAL RULE: Can only bill ONE posterior segment OCT code per encounter
- Choose 92133 OR 92134 OR 92137
- Cannot bill 92133 + 92134 together
- Cannot bill 92134 + 92137 together
- Cannot bill 92133 + 92137 together

Code Selection Decision Tree:

Need OCT Imaging?
│
├── ANTERIOR SEGMENT (cornea, angle, iris)
│   └── 92132 (can bill with posterior segment codes)
│
└── POSTERIOR SEGMENT (Choose ONE only)
    │
    ├── Primary focus: OPTIC NERVE (glaucoma, optic neuropathy)
    │   └── 92133
    │
    ├── Primary focus: RETINA/MACULA (macular disease, diabetic retinopathy)
    │   ├── Standard structural OCT → 92134 ◄ Current Code
    │   └── OCT with angiography (vascular imaging) → 92137
    │
    └── Both optic nerve AND retina need imaging same day?
        ├── Choose PRIMARY reason for imaging
        ├── Bill only ONE code (92133 OR 92134 OR 92137)
        └── Document clinical decision on which to prioritize

Historical Context:

• Pre-2011: Single code 92135 covered all OCT
• 2011: Split into 92132 (anterior), 92133 (optic nerve), 92134 (retina)
• 2017: Code 92137 added for OCT angiography (OCTA)
• 2025: RVU reductions implemented; Stark Law DHS designation added
• Billing changed from per-eye to per-encounter

Why Codes Are Mutually Exclusive:
CMS determined that:

• Typical OCT session captures both optic nerve and retina in standard imaging protocols
• Separate payment for each anatomic area led to overutilization and increased costs
• Payers should pay for PRIMARY reason for OCT imaging
• Providers must choose most clinically relevant code for encounter

Coding Examples

Example 1: Diabetic Macular Edema Monitoring

Patient Presentation: 58-year-old established patient with Type 2 diabetes and diabetic macular edema OU on monthly Eylea injections, presents for routine follow-up and injection.

Pre-visit Assessment:

• Last injection 4 weeks ago
• Vision stable since last visit
• No new symptoms

Examination:

• Visual acuity: 20/50 OD, 20/40 OS (stable)
• IOP: 14 mmHg OU
• Anterior segment: Normal
• Dilated fundus examination:
  • Mild-moderate NPDR with scattered microaneurysms and hemorrhages OU
  • Macular edema assessment requires OCT

OCT Retina Performed:

• High-definition macular cube scans acquired both eyes
• Right eye findings:
  • Central subfield thickness: 325 microns (decreased from 410 microns at last visit)
  • Intraretinal cysts present but reduced in size
  • Subretinal fluid resolved
  • External limiting membrane integrity improving
• Left eye findings:
  • Central subfield thickness: 298 microns (decreased from 380 microns)
  • Minimal intraretinal cystoid spaces
  • No subretinal fluid
  • Ellipsoid zone disruption noted

Interpretation Report:
“OCT of bilateral macula demonstrates improvement in diabetic macular edema both eyes with decreased central thickness and reduced intraretinal fluid compared to prior examination dated [date]. Response to anti-VEGF therapy is favorable. Recommend continuing current treatment regimen.”

Assessment: Diabetic macular edema OU, improving on anti-VEGF therapy

Plan: Proceed with bilateral intravitreal Eylea injections today, continue monthly schedule

Coding:

• 92012-25 - Intermediate eye examination, established patient (modifier 25 for significant separate E/M)
• 92134 - OCT retina, bilateral
• 67028-RT - Intravitreal injection, right eye
• 67028-50-RT - OR code as bilateral with 50 modifier depending on payer preference

Diagnoses:

• E11.3512 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
• E11.3511 - Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
• H35.81 - Retinal edema (can add if needed)

Supporting Documentation:

• OCT report with measurements and comparison to prior
• Images stored in PACS or EMR
• Examination note documenting clinical correlation

Medical Necessity: OCT essential for monitoring treatment response and guiding continuation of anti-VEGF therapy.

Example 2: Age-Related Macular Degeneration Diagnosis

Patient: 74-year-old new patient referred for metamorphopsia (distorted vision) and decreased central vision right eye for 3 weeks.

History:

• Gradual onset blurred central vision OD
• Straight lines appear wavy
• No pain, no floaters
• No previous retinal problems

Examination:

• Visual acuity: 20/80 OD, 20/25 OS
• Amsler grid: Central distortion and scotoma OD, normal OS
• Dilated fundus examination:
  • OD: Subretinal hemorrhage and grayish-green lesion temporal to fovea, suggesting choroidal neovascular membrane
  • OS: Large soft drusen scattered throughout macula

OCT Retina Performed:

• Detailed macular scans both eyes to characterize pathology

Right eye OCT findings:

• Subretinal hyperreflective material (SHRM) consistent with CNV
• Intraretinal fluid with cystoid spaces
• Subretinal fluid collection
• Disruption of ellipsoid zone and external limiting membrane
• Central subfield thickness: 475 microns (severely elevated)
• Pigment epithelial detachment (PED) noted

Left eye OCT findings:

• Multiple medium-large drusen
• Drusenoid PED
• No intraretinal or subretinal fluid
• Central thickness: 265 microns (normal)
• Ellipsoid zone intact

Interpretation: “OCT right eye demonstrates findings consistent with active choroidal neovascularization with associated intraretinal and subretinal fluid, characteristic of exudative age-related macular degeneration. Left eye shows drusen with drusenoid PED, consistent with intermediate dry AMD. Recommend urgent anti-VEGF therapy for right eye.”

Assessment:

• Exudative (wet) age-related macular degeneration, right eye (new diagnosis)
• Intermediate dry age-related macular degeneration, left eye

Plan:

• Initiate anti-VEGF therapy (Eylea) for right eye
• Schedule injection for this week
• Monitor left eye for conversion to wet AMD
• Consider AREDS2 vitamins

Coding:

• 92004 - Comprehensive ophthalmological examination, new patient
• 92134 - OCT retina, bilateral
• 92250 - Fundus photography with interpretation (if photos taken)

Diagnoses:

• H35.3211 - Exudative age-related macular degeneration, right eye, with active choroidal neovascularization
• H35.3622 - Drusen (degenerative) of macula, left eye

Medical Necessity: OCT crucial for diagnosing wet AMD, differentiating from dry AMD, quantifying fluid, and establishing baseline for treatment monitoring.

Example 3: Macular Hole Assessment

Patient: 68-year-old established patient reports sudden central blur and distortion in left eye for 5 days.

Examination:

• Visual acuity: 20/20 OD, 20/100 OS
• Dilated exam OS: Small round defect visible in fovea concerning for macular hole
• Watzke-Allen sign positive (suggesting full-thickness macular hole)

OCT Retina Performed to confirm diagnosis and stage macular hole:

Left eye OCT findings:

• Full-thickness macular hole with well-defined edges
• Diameter of hole: 450 microns
• Small amount of subretinal fluid at base
• Surrounding intraretinal cysts
• Posterior vitreous detachment present with persistent vitreomacular traction
• No epiretinal membrane

Interpretation: “OCT left eye confirms full-thickness macular hole, Stage 3 (by Gass classification), approximately 450 microns in diameter with surrounding intraretinal fluid and persistent vitreomacular traction. Surgical intervention recommended.”

Assessment: Full-thickness macular hole, left eye, Stage 3

Plan: Referral to retina specialist for pars plana vitrectomy with membrane peel and gas tamponade

Coding:

• 92012 or 92014 - Eye examination depending on complexity
• 92134 - OCT retina (critical for diagnosis and surgical planning)

Diagnosis:

• H35.342 - Macular hole, left eye

Medical Necessity: OCT is gold standard for confirming macular hole diagnosis, determining stage, measuring size (affects prognosis), and identifying associated vitreomacular traction.

Example 4: Cannot Bill with Optic Nerve OCT - Code Selection Decision

Patient: 65-year-old with glaucoma AND diabetic retinopathy, presents for combined follow-up.

Examination performed:

• Glaucoma assessment: IOP, optic nerve examination
• Diabetic retinopathy assessment: Macular examination

Imaging Considerations:

• Would benefit from BOTH optic nerve OCT (glaucoma) AND macular OCT (diabetic retinopathy)
• However: CANNOT bill 92133 and 92134 together same encounter

Decision Required - Choose ONE:

Option 1: Bill 92133 (Optic Nerve OCT)

• If primary reason for visit is glaucoma management
• If glaucoma is more urgent/unstable condition
• If diabetic retinopathy is stable and doesn’t require OCT today

Option 2: Bill 92134 (Retina OCT)

• If diabetic macular edema is primary concern
• If macular pathology requires monitoring today
• If glaucoma is stable and doesn’t require OCT today

Clinical Decision in This Case:
Patient has diabetic macular edema that has been worsening; glaucoma is stable on current medications.

Coding:

• 92012 - Intermediate examination
• 92134 - OCT retina (chose retina over optic nerve based on clinical priority)
• 92083 - Visual field testing (for glaucoma monitoring without OCT)

Diagnoses:

• E11.3513 - Type 2 DM with diabetic macular edema, bilateral (primary)
• H40.1113 - Primary open-angle glaucoma, bilateral, moderate stage (secondary)

Documentation: “OCT of macula performed today to assess diabetic macular edema status given recent worsening. Optic nerve OCT deferred as glaucoma stable on current therapy; will obtain at next visit in 3 months.”

Alternative Approach:
If both truly needed same day:

• Stage visits: OCT optic nerve today (92133), schedule return visit in 1-2 weeks for OCT retina (92134)
• Different dates allow billing both codes
• Document medical necessity for both

Example 5: OCT with Fluorescein Angiography

Patient: 55-year-old with central serous chorioretinopathy (CSCR), subretinal fluid present on examination.

Clinical Question: Is there active leakage? Where is the leakage site?

Testing Performed:

1. OCT retina: Quantify subretinal fluid, assess RPE changes
2. Fluorescein angiography: Identify leakage point

OCT Findings:

• Neurosensory detachment with subretinal fluid
• Central thickness 425 microns
• “Thumb-like” protrusion from RPE
• No intraretinal fluid

Fluorescein Angiography Findings:

• Classic “smokestack” appearance of dye leakage
• Focal leakage point identified at 6:00 position from fovea

Coding:

• 92012 or 92014 - Eye examination
• 92134 - OCT retina
• 92235 - Fluorescein angiography

Both imaging modalities separately billable - different technologies providing complementary information.

Diagnosis:

• H35.711 - Central serous chorioretinopathy, right eye

Medical Necessity: OCT quantifies fluid; angiography localizes leakage for potential focal laser treatment.

Example 6: Epiretinal Membrane Monitoring

Patient: 71-year-old with known epiretinal membrane (macular pucker) OU, vision slowly declining.

History: Metamorphopsia and gradual vision decrease both eyes over 18 months

Examination:

• Visual acuity: 20/50 OU (decreased from 20/40 six months ago)
• Dilated exam: Visible epiretinal membranes with macular distortion OU

OCT Retina:
Bilateral findings:

• Epiretinal membrane with retinal surface wrinkling
• Intraretinal cysts in inner nuclear layer
• Partial posterior vitreous detachment
• Central thickness: 385 microns OD, 402 microns OS (increased from prior)
• Foveal contour distortion

Interpretation: “Bilateral epiretinal membranes with associated intraretinal cystoid changes and progressive thickening compared to examination 6 months ago. Worsening clinical picture correlates with decreasing visual acuity. Surgical intervention (vitrectomy with membrane peel) may be considered given progression.”

Assessment: Epiretinal membrane OU, progressive

Plan: Discuss surgical options vs observation; refer to retina specialist if patient desires surgery

Coding:

• 92014 - Comprehensive examination, established patient
• 92134 - OCT retina, bilateral

Diagnosis:

• H35.373 - Epiretinal membrane, bilateral

Medical Necessity: OCT essential for monitoring progression of epiretinal membrane, documenting thickening and cystoid changes, and supporting surgical decision-making.

Documentation Requirements

Medical Necessity Documentation:

Clinical Indication Required:

• Signs, symptoms, or clinical findings supporting need for retinal OCT
• How results will impact diagnosis or treatment decisions
• Risk factors or conditions warranting imaging

Indications Supporting Medical Necessity:

• Decreased visual acuity with macular pathology suspected
• Metamorphopsia (distorted vision)
• Central scotoma
• Known macular disease requiring monitoring
• Diabetic retinopathy with macular involvement
• Age-related macular degeneration
• Macular edema of any etiology
• Retinal vascular occlusions
• Unexplained vision loss
• Monitoring response to treatment (anti-VEGF, laser, surgery)
• Pre-operative planning for macular surgery

Interpretation Report Must Contain:

Required Elements:

1. Patient Demographics:
   • Patient name, date of birth, medical record number
   • Date of service
   • Ordering physician
2. Technical Quality:
   • Signal strength or quality score
   • Statement about image quality (good, fair, poor)
   • Any limitations affecting interpretation
3. Quantitative Measurements:
   • Central subfield thickness (within 1mm diameter circle)
   • Central thickness (various definitions depending on machine)
   • Macular volume (if measured)
   • ETDRS sector thicknesses (if applicable)
   • Comparison to normative database with percentiles
   • Must include actual numeric values (not just color maps)
4. Qualitative Findings:
   • Retinal layers:
     • Architecture (normal vs disrupted)
     • Layer identification: ILM, RNFL, GCL-IPL, INL, OPL, ONL, ELM, photoreceptors (EZ/IS-OS), RPE
     • Specific layer disruptions noted
   • Fluid assessment:
     • Intraretinal fluid (IRF): present/absent, location, severity
     • Subretinal fluid (SRF): present/absent, extent
     • Sub-RPE fluid: present/absent
   • Structural abnormalities:
     • Epiretinal membrane
     • Vitreomacular traction
     • Macular hole (size, stage)
     • Drusen (size, location)
     • Pigment epithelial detachment (PED)
     • Geographic atrophy
     • Choroidal neovascularization (CNV)
     • Retinal detachment
   • Choroid:
     • Choroidal thickness if measured
     • Choroidal abnormalities
5. Comparison to Prior Studies:
   • State prior examination date
   • Specific comparison of key parameters
   • Trend analysis: stable, improving, worsening
   • Quantify changes in thickness
   • Describe changes in pathology
6. Color-Coded Maps:
   • Reference to thickness maps
   • Deviation maps interpretation
   • Significance of color-coded abnormalities
7. Clinical Correlation:
   • Correlation with examination findings
   • Correlation with symptoms
   • Correlation with visual acuity changes
   • Consistency with clinical diagnosis
8. Impression/Conclusion:
   • Summary of key findings
   • Primary diagnosis(es)
   • Significance of findings
   • Recommendations for management or follow-up imaging
9. Physician Signature:
   • Interpreting physician name
   • Credentials
   • Date of interpretation
   • Electronic or written signature

Image Storage Requirements:

• Digital images stored in PACS or EMR
• Images must be retrievable for audit
• Key representative images should be in report or attached
• Raw data retained per institutional/regulatory requirements
• Images should demonstrate findings described in report

Documentation Pitfalls to Avoid:

• Generic template reports without patient-specific findings
• Missing quantitative measurements
• No comparison to prior studies when available
• Inadequate description of pathology
• No physician signature
• Poor quality images without documentation of technical limitations
• Copy-paste errors from prior reports
• Contradiction between images and interpretation

Billing Guidelines and Best Practices

Critical Billing Rule - Mutually Exclusive Codes:

CANNOT Bill Together Same Encounter:

• 92134 (retina OCT) + 92133 (optic nerve OCT)
• 92134 (retina OCT) + 92137 (retina OCTA)
• 92133 (optic nerve OCT) + 92137 (retina OCTA)

Can ONLY bill ONE posterior segment OCT code per patient encounter

Why Mutually Exclusive:

• CMS policy: Standard OCT protocols typically image both optic nerve and macula
• Separate payment for each area determined to be duplicative
• Must choose PRIMARY clinical indication for imaging
• Code most clinically relevant reason for OCT

How to Choose:

• Use 92133 if primary indication is glaucoma, optic neuropathy, papilledema
• Use 92134 if primary indication is macular disease, diabetic retinopathy, vascular occlusion
• Use 92137 if OCTA vascular imaging is primary need
• Document clinical decision-making in medical record

If Both Needed:

• Stage visits on different dates to bill both codes
• Document medical necessity for both
• Typical approach: Most urgent condition imaged today, other at follow-up

Bilateral vs Unilateral Billing:

Critical Rule:

• Bill ONE unit whether imaging one eye or both eyes
• Payment is per-encounter, not per-eye
• Do NOT use modifier 50 (bilateral)
• Do NOT bill 92134 twice with RT and LT
• Quantity field = “1” regardless of number of eyes imaged

This Changed in 2011:

• Pre-2011: Could bill per eye
• 2011-present: Per-encounter billing only

Professional vs Technical Component:

Global Service (No Modifier):

• Includes both image acquisition AND interpretation
• Full payment
• Provider owns equipment and interprets

Modifier TC (Technical Component):

• Image acquisition only
• Equipment, staff, supplies
• Approximately 60% of total RVU
• Billed by facility owning equipment

Modifier 26 (Professional Component):

• Interpretation and report only
• Approximately 40% of total RVU
• Billed by physician interpreting images acquired elsewhere

Split Billing Example:

• Hospital outpatient department performs OCT: Bills 92134-TC
• Physician interprets images: Bills 92134-26
• Total payment = TC + 26 = global fee

Frequency and Medical Necessity:

Medicare Guidelines:

• No specific frequency limitation for 92134
• Each test must be medically necessary
• Document reason for testing
• Typical intervals depend on condition:
  • Stable chronic conditions: 6-12 months
  • Active disease or treatment: Monthly to quarterly
  • Acute conditions: As clinically indicated

Medical Necessity Requires:

• Signs/symptoms/findings supporting need
• How results will affect management
• Avoid routine screening without indication

Common Acceptable Frequencies:

• Wet AMD on anti-VEGF: Monthly (monitoring treatment)
• Diabetic macular edema: Monthly to quarterly
• Stable dry AMD: 6-12 months
• Epiretinal membrane: 6-12 months if stable
• Macular hole: Pre-op, post-op follow-ups

Designated Health Services (Stark Law):

Important Compliance Issue - 2025 Change:

• CPT 92134 added to Stark Law DHS list in 2025
• Physicians with ownership in OCT equipment must comply with Stark regulations
• Self-referral restrictions apply
• Must meet exception requirements
• Affects physician compensation arrangements
• Productivity-based payment restrictions
• In-office ancillary services exception criteria must be met

Implications:

• Cannot refer patients to entity where physician has financial interest unless exception met
• Compensation cannot vary with volume/value of referrals
• Group practice requirements must be met
• Documentation of compliance essential

NCCI Edits and Bundling:

Codes That May Bundle with 92134:

• Fundus photography (92250): Check current NCCI edits
  • Some versions bundle 92250 into 92134
  • Modifier 59 may be needed if both truly necessary and separately documented
  • Must demonstrate distinct clinical value of each
• Extended ophthalmoscopy (92225-92226): May have edits

Separately Billable with 92134:

• Examination codes (92002-92014): Different service types
• Fluorescein angiography (92235): Different modality
• Visual field testing (92081-92083): Different test
• Anterior segment OCT (92132): Different anatomic area
• Procedures (injections, laser): Different services

Medicare Coverage:

Covered When:

• Medically necessary for diagnosis or management
• Documented clinical indication
• Appropriate diagnosis code supporting need
• Results will impact patient care

Not Covered:

• Routine screening without symptoms
• Normal eye examination without specific indication
• Testing for physician convenience
• Duplicate testing same day without quality issues
• More frequent than medically necessary

Prior Authorization:

• Medicare: Generally not required for 92134
• Medicare Advantage: May require prior authorization (check plan)
• Commercial payers: Variable; some require auth
• Submit clinical indication and diagnosis when required

Advance Beneficiary Notice (ABN):

When to Provide ABN:

• Medicare beneficiary and coverage uncertain
• Frequency may exceed medical necessity
• Diagnosis may not support coverage
• Screening indication without symptoms
• Patient wants testing despite lack of clear indication

Modifier Usage with ABN:

• GA modifier: ABN obtained, patient agrees to pay if denied
• GZ modifier: Service expected to deny, ABN not obtained (high audit risk)

Cosmetic vs Functional:

• All OCT imaging for retinal disease is considered diagnostic/medical
• No “cosmetic” indication for retinal OCT
• Always requires medical necessity

Common Billing Errors to Avoid:

1. Billing 92133 and 92134 together same day - Mutually exclusive
2. Billing modifier 50 or RT/LT separately - Per-encounter code, not per-eye
3. Billing 92134 twice for bilateral - Only bill once
4. Using modifier 51 - Auto-applied by payers; don’t append
5. Missing interpretation report - Professional component requires documentation
6. Inadequate medical necessity - Must document clinical indication
7. Billing for screening - Requires symptoms or findings
8. Poor image quality without documentation - Note technical limitations
9. Not comparing to prior - Should reference prior studies when available
10. Using wrong code for primary indication - Choose 92133 vs 92134 vs 92137 appropriately

Best Practices:

Documentation:

• Individualized interpretation reports (not templates alone)
• Specific measurements documented
• Comparison to prior studies
• Clinical correlation stated
• Clear impression/recommendation

Medical Necessity:

• Document clinical indication clearly
• How results will guide management
• Appropriate diagnosis codes
• Frequency justified by clinical condition

Compliance:

• Know Stark Law implications if equipment owned
• Follow NCCI bundling rules
• Appropriate modifier use
• Accurate coding based on service performed
• Quality images with proper technique

Coding Accuracy:

• Choose correct posterior segment code (92133 vs 92134 vs 92137)
• Bill per-encounter, not per-eye
• Split professional/technical appropriately
• Use modifiers correctly

Clinical Indications and Diagnosis Codes

Primary Diagnoses Supporting Medical Necessity for Retinal OCT:

Macular Degeneration:

• H35.30 - Unspecified macular degeneration
• H35.31x1-H35.31x4 - Nonexudative (dry) AMD with various stages and laterality
• H35.32x1-H35.32x4 - Exudative (wet) AMD with various stages and laterality
• H35.3611-H35.3633 - Drusen of macula (various types and laterality)

Diabetic Retinopathy and Macular Edema:

• E08.3x-E13.3x - Diabetes with ophthalmic complications (specify type and stage)
• E11.311x - Type 2 DM with unspecified diabetic retinopathy with macular edema
• E11.32x - Type 2 DM with mild NPDR
• E11.33x - Type 2 DM with moderate NPDR
• E11.34x - Type 2 DM with severe NPDR
• E11.35x - Type 2 DM with proliferative diabetic retinopathy
• E11.36x - Type 2 DM with diabetic macular edema resolved
• Sixth character specifies laterality and macular edema status

Retinal Vascular Occlusions:

• H34.811-H34.8393 - Central retinal vein occlusion (with/without macular edema, laterality)
• H34.821-H34.8393 - Branch retinal vein occlusion
• H34.11-H34.13 - Central retinal artery occlusion
• H34.21-H34.23 - Branch retinal artery occlusion

Macular Structural Abnormalities:

• H35.341-H35.349 - Macular hole (specify laterality and stage)
• H35.371-H35.379 - Epiretinal membrane/macular pucker
• H35.721-H35.723 - Serous detachment of retinal pigment epithelium
• H35.731-H35.733 - Hemorrhagic detachment of RPE

Central Serous Chorioretinopathy:

• H35.711-H35.713 - Central serous chorioretinopathy (CSCR)

Retinal Edema:

• H35.81 - Retinal edema (unspecified)
• H35.82 - Retinal ischemia

Vitreomacular Interface Disorders:

• H43.811-H43.813 - Vitreous degeneration
• H43.821-H43.823 - Vitreomacular adhesion
• H43.82x - Other vitreomacular disorders

Retinal Detachment:

• H33.001-H33.059 - Retinal detachment with retinal break
• H33.20-H33.23 - Serous retinal detachment

Hereditary Retinal Dystrophies:

• H35.50-H35.54 - Hereditary retinal dystrophy
• H35.51-H35.52 - Vitreoretinal dystrophies
• H35.53 - Dystrophies primarily involving RPE

Other Retinal Disorders:

• H35.00-H35.07 - Background retinopathy and retinal vascular changes
• H35.171-H35.179 - Retinal telangiectasis
• H31.001-H31.419 - Choroidal disorders (various)
• H43.1xx - Vitreous hemorrhage

Supporting Diagnoses:

• H53.011-H53.043 - Amblyopia (pediatric cases requiring OCT)
• H53.121-H53.139 - Transient visual loss
• H53.2 - Diplopia (if macular pathology suspected)
• H53.411-H53.469 - Visual field defects

Post-Procedural Monitoring:

• Z98.89 - Other specified postprocedural states (after retinal surgery, injection)
• Use with primary retinal diagnosis

Diagnoses Generally NOT Supporting Medical Necessity:

• Routine eye examination without findings (Z01.00)
• Refractive error alone without retinal pathology
• Normal examination results
• Cosmetic concerns (not applicable to retinal OCT)

Incorrect Diagnosis Coding Pitfalls:

• Using unspecified codes when specific laterality/stage available
• Missing sixth character for diabetes codes (laterality/macular edema)
• Using screening codes without findings
• Insufficient specificity (e.g., H35.30 unspecified when specific AMD type known)
• Not coding to highest specificity available

Diagnosis Documentation Tips:

• Always specify laterality
• For diabetes: Include type, stage of retinopathy, presence/absence of macular edema
• For AMD: Specify dry vs wet, stage, presence of CNV
• Document concurrent conditions affecting retina
• Link diagnosis to OCT findings in interpretation report