92137

👁️ CPT 92137 — Computerized Ophthalmic Diagnostic Imaging, Posterior Segment; Retina, Including OCT Angiography

Quick Reference

wRVU: 0.62 | Global Period: XXX (Global surgery concept does not apply — diagnostic test) | Assistant Payable: ❌ No | Bilateral Indicator: 3

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📋 Clinical Description

CPT 92137 describes computerized ophthalmic diagnostic imaging of the posterior segment retina that incorporates both standard structural optical coherence tomography (OCT) and OCT angiography (OCTA) in a single session, unilateral or bilateral, with physician interpretation and written report.^1,2 This code is the most clinically advanced in the posterior segment OCT family, distinguished from 92134 (structural retinal OCT only) by the addition of OCTA — an infusion-free, dye-free technique that maps retinal and choriocapillaris blood flow using optical motion contrast derived from repeated OCT B-scan acquisitions at the same retinal location.³ Unlike fluorescein angiography (92235) or ICG angiography (92240), OCTA requires no intravenous dye injection, produces no systemic adverse reactions, and generates en face vascular flow maps at multiple retinal depth levels simultaneously; it does not, however, capture dynamic leakage information that FA and ICG provide and that may still be clinically required in select cases.^3,4

Choroidal neovascularization (CNV) is the hallmark of neovascular (exudative) AMD and the most common indication driving OCTA; it represents pathological growth of vessels from the choriocapillaris through Bruch’s membrane into the sub-RPE or subretinal space, causing progressive fluid accumulation, hemorrhage, and rapid central vision loss if untreated.⁵ OCTA enables direct visualization and morphologic classification of CNV (Types 1, 2, and 3), quantification of lesion area and flow void patterns, and noninvasive monitoring of treatment response — information that drives anti-VEGF injection timing decisions without the procedural burden of dye-based imaging.

This procedure may be performed in the following clinical contexts:

• Active neovascular AMD monitoring — Serial OCTA documents CNV lesion size, flow status (active vs. inactive), and response to intravitreal anti-VEGF therapy; used to guide treat-and-extend protocol adjustments between injections
• Suspected new CNV onset — OCTA provides rapid, noninvasive characterization of suspected CNV in patients presenting with new visual disturbance, metamorphopsia, or macular thickening on structural OCT B-scan
• Diabetic retinopathy and macular ischemia assessment — OCTA maps the superficial and deep capillary plexuses and the choriocapillaris, identifying retinal nonperfusion zones, foveal avascular zone (FAZ) enlargement, and microaneurysm perfusion status to inform treatment planning (PRP, anti-VEGF, or observation)
• Retinal vascular occlusion evaluation — OCTA delineates ischemic vs. non-ischemic patterns in CRVO and BRVO, identifying areas of capillary dropout and collateral formation that govern management; etiology codes such as H34.8110 (CRVO, right eye, with macular edema) should be documented with full laterality and macular edema status
• CNV from non-AMD etiologies — OCTA detects and monitors CNV secondary to pathologic myopia, angioid streaks, inflammatory conditions (punctate inner choroidopathy, multifocal choroiditis), or trauma; when applicable, the underlying etiology code supplements the retinal diagnosis and supports medical necessity

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🔬 Anatomical & Procedural Considerations

Imaging Component	Mechanism / Technology	Key Clinical / Coding Notes
Structural OCT (B-scan)	Sequential A-scan acquisitions build cross-sectional B-scan images differentiating individual retinal layers (ILM, NFL, GCL, INL, OPL, ONL, ELM, RPE, Bruch’s membrane) using near-infrared light	Provides retinal layer thickness maps, fluid quantification (subretinal fluid, intraretinal fluid, sub-RPE fluid), and structural morphology; this structural component overlaps with 92134 — do NOT bill 92134 separately on the same day as 92137
OCT Angiography (OCTA)	Motion contrast algorithm compares amplitude/phase variance between sequential B-scans at the same retinal location: static tissue = no signal; moving blood = detectable signal variance; software generates 3D en face vascular flow maps	Produces depth-resolved angiographic maps of the superficial capillary plexus, deep capillary plexus, outer retina, and choriocapillaris; identifies CNV morphology and type, FAZ area and circularity, retinal nonperfusion zones, and choriocapillaris flow voids — no contrast dye is administered
Combined Co-registered Analysis	Structural B-scans and en face OCTA flow maps are co-registered in the same imaging session; multimodal interpretation is performed from a single acquisition dataset	The interpretation report must document BOTH structural OCT findings AND OCTA angiographic flow findings; a report containing only retinal layer thickness data without flow map analysis is insufficient to support 92137 on audit

Clinical Pearl

92137 is a standalone code — not an add-on to 92134. When OCTA is performed, bill 92137 only — not 92134 plus a separate angiographic code. The AMA CPT 2025 parenthetical explicitly prohibits reporting 92133, 92134, and 92137 at the same patient encounter.¹ The physician interpretation report must document both the structural OCT component and the OCTA flow findings; a report limited to structural retinal layers without angiographic analysis will not support 92137 on audit and will be downcoded to 92134. Flow maps, CNV characterization, FAZ metrics, or vascular perfusion findings must appear in the dictated report.

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✅ Procedure Includes

• Structural optical coherence tomography B-scan imaging of the posterior segment retina
• OCT angiography using optical motion contrast without injected dye (infusion-free angiography)
• En face flow map generation at multiple retinal depth levels (superficial and deep capillary plexuses, outer retina, choriocapillaris)
• Co-registration of structural and angiographic data within a single acquisition dataset
• Computer processing, 3D reconstruction, and image artifact assessment
• Physician interpretation with written report documenting both structural OCT findings and OCTA flow data
• Unilateral or bilateral imaging billed as a single service — one unit of service regardless of the number of eyes examined

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❌ Excludes / Do Not Report Together

Code	Description	Relationship to 92137
92134	OCT, posterior segment, retina — structural only	Mutually exclusive at the same patient encounter per AMA CPT 2025 parenthetical note and NCCI; 92137 subsumes the structural retinal OCT component; never bill 92134 on the same day as 92137
92133	OCT, posterior segment, optic nerve	Mutually exclusive at the same patient encounter per the same AMA parenthetical; addresses a different anatomical target (optic nerve vs. retina) but the blanket exclusion applies; NCCI enforces this edit
92132	OCT, anterior segment	NOT included in the AMA parenthetical prohibition — anterior and posterior segment OCT are anatomically distinct services; separately reportable in principle, but verify current payer-specific policy before billing on the same day
92235	Fluorescein angiography with I&R	Separately reportable when clinically distinct and individually documented; NCCI PTP edits between 92137 and 92235 were eliminated effective October 1, 2025 (quarterly implementation April 1, 2026) following AAO advocacy; some payers may still require modifier -59 until system updates complete5
92240	ICG angiography with I&R	Separately reportable; NCCI PTP edits eliminated same date as 922355
92242	Combined FA + ICG angiography with I&R	Separately reportable; same NCCI edit removal applies5
92250	Fundus photography with I&R	NCCI indicator 1 (can be unbundled when appropriate and individually documented); verify current quarter NCCI table
E/M codes (992xx / 920xx)	Office or eye visit, any level	Separately reportable only when modifier -25 is appended to the E/M code (not to 92137), documenting a significant, separately identifiable E/M service beyond the routine pre-imaging clinical assessment

Bundling Alert — Global Period is XXX, Not 000/010/090

Because 92137 carries a global period of XXX, the standard surgical global period framework does not apply — there is no pre/post-operative period, no bundling of follow-up E/M visits, and no requirement for modifiers -24 or -79. However, payers are expected to impose their own frequency limitations for 92137 similar to fluorescein angiography (92235) — typically a few times per year — rather than the every-28-day interval historically applied to 92134 for anti-VEGF monitoring. Medicare MACs are actively issuing ADRs for 92137 claims that lack individually documented medical necessity, and some commercial payers continue to deny 92137 as investigational. Monitor MAC LCA publications for 92137 frequency and coverage guidance as policies are released.⁴

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🌳 Code Tree — Medicine: Ophthalmology, Special Ophthalmological Services

CPT 92002-92499  Medicine: Ophthalmology
│
├── 92002-92014  Eye Examinations (General and Special Ophthalmological Services)
│
├── 92132  Computerized ophthalmic dx imaging (eg, OCT), anterior segment, with I&R, unilateral or bilateral  (Global: XXX)
│
├── [Parent — not separately billed]  Computerized ophthalmic dx imaging (eg, OCT), posterior segment, with I&R, unilateral or bilateral;
│   ├── 92133  optic nerve  (Global: XXX)
│   ├── 92134  retina  (Global: XXX)
│   └── ▶▶ 92137 ◀◀  retina, including OCT angiography  ← YOU ARE HERE  (Global: XXX)
│
├── 92201/92202  Ophthalmoscopy with retinal drawing; with I&R
├── 92227-92229  Remote imaging services (staff review / MD interpretation / automated analysis)
├── 92235  Fluorescein angiography (includes multiframe imaging) with I&R, unilateral or bilateral  (Global: XXX)
├── 92240  Indocyanine-green angiography with I&R  (Global: XXX)
├── 92242  Combined FA/ICG angiography with I&R  (Global: XXX)
└── 92250  Fundus photography with I&R  (Global: XXX)

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💰 RVU & Reimbursement Profile

Component	Value
Work RVU (wRVU)	0.62 (2025-2026 CMS MPFS data; verify against current year MPFS — wRVU may be adjusted annually; the 2026 CMS Final Rule applied a 2.5% efficiency adjustment to most non-time-based procedure codes)
Global Period	XXX — Global surgery concept does not apply; diagnostic test
Bilateral Indicator	3 — Code represents unilateral or bilateral service; billed once per encounter regardless of number of eyes imaged; NOT subject to standard bilateral payment reduction; do NOT apply modifier -50 or RT + LT to this code
Assistant Surgeon	❌ Not payable — diagnostic imaging procedure; no surgeon role applicable
Co-Surgeon	❌ Not applicable
Team Surgery	❌ Not applicable
PC/TC Split	✅ Yes — PC/TC Indicator 1; global service (no modifier) when physician owns and operates the equipment; professional component (-26) when physician interprets only; technical component (TC) billed by facility or equipment owner
Modifier -51 Exempt	No
Anesthesia	None required; mydriatic drops may be used at physician discretion; no separate anesthesia billing expected
DHS Status	✅ Added to CMS Designated Health Service list effective January 1, 2025 — Stark Law self-referral prohibitions apply; physician group practices with in-office OCTA equipment should review productivity-based compensation models with compliance counsel

Bilateral Billing Rules

92137 has a bilateral indicator of 3, meaning the code is priced for unilateral OR bilateral service as a single fee. Bill 92137 once per encounter regardless of whether OCTA is performed on one eye or both eyes in the same session. Never bill 92137 twice, apply modifier -50, or append-RT +-LT on separate lines. If a commercial payer specifically requests laterality information via their own billing guide, confirm the payer’s instructions — do not assume modifier conventions from surgical or injection codes apply to “unilateral or bilateral” diagnostic imaging codes.

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🏷️ Modifier Reference

Modifier	Name	When to Apply
-26	Professional Component	When the interpreting physician does not own or operate the OCTA equipment (hospital-based clinic, HOPD, or academic faculty setting); physician bills for interpretation and report only; facility separately bills -TC
-TC	Technical Component	Billed by the facility, hospital, or independent equipment owner for image acquisition, equipment, supplies, and technical staff; never billed by the same entity billing -26 under the same TIN
-25	Significant, Separately Identifiable E/M	Applied to the E/M code only — NOT to 92137 — when a medically necessary office visit is documented separately on the same date; the E/M must be substantively distinct from the pre-imaging clinical assessment
-59	Distinct Procedural Service	When billing 92137 with 92235, 92240, or 92242 on the same day; NCCI PTP edits between these code pairs were eliminated effective October 2025 / April 2026 implementation, but some payers may still require -59 until systems update — verify current payer policy before omitting
-51	Multiple Procedures	When 92137 is billed alongside another separately payable procedure subject to multiple procedure payment reduction; apply to the lower-valued code; confirm payer applicability for diagnostic imaging codes
-GX	Notice of Exclusion from Medicare Benefits	Applied when a valid ABN has been issued and the patient agrees to pay out-of-pocket for OCTA with a non-covered indication or frequency exceeded
-GY	Statutory Exclusion	For OCTA categorically non-covered by the payer; no ABN required; signals a non-payable claim
-52	Reduced Services	OCTA partially completed and insufficient flow map data obtained; document reason; consider whether downcode to 92134 is more appropriate if only structural OCT data was acquired
-53	Discontinued Procedure	Procedure terminated before any usable images acquired due to patient safety, cooperation failure, or equipment failure; document reason thoroughly

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🩺 Common ICD-10-CM Pairings

Exudative (Neovascular / Wet) Age-Related Macular Degeneration

ICD-10 Code	Description	HCC?	Clinical Notes
H35.3211	Exudative AMD, right eye, with active choroidal neovascularization	❌ No	Primary indication for OCTA in AMD; document CNV type (1, 2, or 3), flow area, and lesion borders in interpretation report; query provider for CNV activity status if not explicitly stated
H35.3212	Exudative AMD, right eye, with inactive choroidal neovascularization	❌ No	Use when CNV has been treated and is quiescent; OCTA ordered to confirm inactivity and re-establish imaging baseline prior to extending injection intervals
H35.3213	Exudative AMD, right eye, with inactive scar	❌ No	End-stage fibrotic disciform scar; OCTA used to confirm absence of active flow at scar margins and monitor for nascent CNV at adjacent areas
H35.3221	Exudative AMD, left eye, with active CNV	❌ No	Same coding logic as right-eye equivalent; specify laterality from documentation; do not default to bilateral unless both eyes meet the diagnosis at the same encounter
H35.3231	Exudative AMD, bilateral, with active CNV	❌ No	Appropriate only when bilateral active CNV is explicitly documented in both eyes at the same encounter

Nonexudative (Dry) AMD — Advanced Stages with Geographic Atrophy

ICD-10 Code	Description	HCC?	Clinical Notes
H35.3113	Nonexudative AMD, right eye, advanced atrophic without subfoveal involvement	❌ No	OCTA used to assess choriocapillaris flow void at GA lesion borders and detect nascent CNV; specify whether subfoveal involvement is absent — requires provider documentation
H35.3114	Nonexudative AMD, right eye, advanced atrophic with subfoveal involvement	❌ No	Geographic atrophy involving the fovea with central scotoma; OCTA monitors for conversion to exudative AMD and characterizes choriocapillaris loss
H35.3123	Nonexudative AMD, left eye, advanced atrophic without subfoveal involvement	❌ No	Left-eye equivalent; document bilateral involvement separately at the correct stage per eye
H35.3124	Nonexudative AMD, left eye, advanced atrophic with subfoveal involvement	❌ No	See right-eye equivalent notes

Diabetic Retinopathy with Macular Edema

ICD-10 Code	Description	HCC?	Clinical Notes
E11.3411	T2DM with severe NPDR with macular edema, right eye	✅ HCC 18	OCTA maps FAZ area, retinal perfusion density, and peripheral nonperfusion zones; documentation must support severe NPDR (distinct from moderate); HCC 18 capture requires the diabetes code, not a standalone retinal code
E11.3412	T2DM with severe NPDR with macular edema, left eye	✅ HCC 18	Code as specifically as documentation supports laterality and DR severity
E11.3413	T2DM with severe NPDR with macular edema, bilateral	✅ HCC 18	Use bilateral code only when both eyes meet severe NPDR + DME criteria at the same encounter
E11.3511	T2DM with PDR with macular edema, right eye	✅ HCC 18 + HCC 122	HCC 122 (Proliferative DR and Vitreous Hemorrhage) adds RAF score — critical for risk adjustment capture; query provider for PDR vs. NPDR when documentation is unclear or does not specify stage
E11.3512	T2DM with PDR with macular edema, left eye	✅ HCC 18 + HCC 122	Same coding and HCC logic
E11.3513	T2DM with PDR with macular edema, bilateral	✅ HCC 18 + HCC 122	Bilateral PDR with DME; verify both eyes explicitly documented at this severity level

Retinal Vascular Occlusion with Macular Edema

ICD-10 Code	Description	HCC?	Clinical Notes
H34.8110	Central retinal vein occlusion, right eye, with macular edema	❌ No	OCTA maps ischemic nonperfusion and CME extent; CRVO vs. BRVO must be specifically distinguished — they are separate code families and affect management
H34.8120	Central retinal vein occlusion, left eye, with macular edema	❌ No	Query for laterality and macular edema documentation if not explicitly stated
H34.8310	Tributary (branch) retinal vein occlusion, right eye, with macular edema	❌ No	BRVO; OCTA maps the nonperfused segment and collateral vessel development in the affected quadrant
H34.8320	Tributary (branch) retinal vein occlusion, left eye, with macular edema	❌ No	See right-eye equivalent notes

Retinal Neovascularization — Non-AMD Etiology

ICD-10 Code	Description	HCC?	Clinical Notes
H35.051	Retinal neovascularization, NEC, right eye	❌ No	Use when CNV or retinal neovascularization occurs outside the context of AMD, DR, or RVO (e.g., myopia, inflammatory chorioretinopathy, angioid streaks); document underlying etiology code when known
H35.052	Retinal neovascularization, NEC, left eye	❌ No	Same coding logic; laterality required
H35.053	Retinal neovascularization, NEC, bilateral	❌ No	Use only when bilateral disease is explicitly documented

Coding Specificity Reminder

The most commonly missed specificity axes for 92137 ICD-10-CM pairings are: (1) AMD subtype — dry (H35.31xx) vs. wet (H35.32xx) must be distinguished, with further 7th-character specificity for CNV activity status (active/inactive/scar) in exudative AMD; (2) laterality — right, left, and bilateral codes exist at the most granular levels; bilateral codes are used only when BOTH eyes meet the diagnosis as documented; and (3) diabetic retinopathy stage — mild, moderate, and severe NPDR, and PDR, drive different HCC assignments and must not be interchanged without provider documentation support. Query the provider when the clinical note does not specify CNV activity, DR severity, or laterality. ICD-10-CM specificity requirements are not optional.

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🏥 MS-DRG Considerations (Inpatient)

Inpatient Coding Reminder

CPT 92137 is performed exclusively in the outpatient / office setting. There are no routine MS-DRG assignments for this procedure — inpatient admission solely for OCT angiography of the retina is not clinically warranted and would not be supported by any MAC, utilization review body, or payer. If a patient admitted for an unrelated inpatient diagnosis (e.g., hypertensive emergency, DKA) also undergoes OCTA during the same stay, a facility ICD-10-PCS code may be assigned for completeness but will carry no meaningful DRG impact. Inpatient retinal conditions that do drive DRG assignment (AMD, diabetic retinopathy, RVO) group to MDC 02 (Diseases and Disorders of the Eye) based on the principal diagnosis and CC/MCC tier — not on the diagnostic imaging code. See the ICD-10-PCS section below.

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🔧 ICD-10-PCS Equivalents (Inpatient Facility Coding)

Note

OCT angiography is performed almost exclusively in the outpatient setting. ICD-10-PCS coding for OCTA during an inpatient encounter is a rare, incidental scenario. When assigned, the code resides in Section B (Imaging), Body System 8 (Eye), Root Type Y (Other Imaging) — appropriate because OCT uses near-infrared light, not ionizing radiation; the PCS definition of Computerized Tomography (root type 2) requires “multiple exposures of external ionizing radiation,” which OCT does not meet. Contrast is Z (None) since OCTA is infusion-free. Verify body part character values against the current fiscal year ICD-10-PCS tabular list. These codes will not influence DRG assignment.

PCS Code	Full Description	Applicable Scenario
B8Y0ZZZ	Other Imaging, Eye, Right Eye, No Contrast, No Qualifier	OCTA of right retina during inpatient stay — verify body part character 0 against current ICD-10-PCS B8Y table
B8Y1ZZZ	Other Imaging, Eye, Left Eye, No Contrast, No Qualifier	OCTA of left retina — verify body part character 1
B8YJZZZ	Other Imaging, Eye, Bilateral, No Contrast, No Qualifier	OCTA of both eyes — verify bilateral body part character J against current ICD-10-PCS tables

PCS Character Analysis — B8Y0ZZZ

Position	Character	Value	Definition
1	Section	B	Imaging — non-operative diagnostic imaging procedures
2	Body System	8	Eye
3	Root Type	Y	Other Imaging — “Other specified modality for visualizing a body part”; appropriate for OCT technology, which uses non-ionizing near-infrared light
4	Body Part	0	Eye, Right — verify this character value in the current ICD-10-PCS B8Y table
5	Contrast	Z	None — OCTA is infusion-free; no contrast agent is administered
6	Qualifier	Z	None
7	Qualifier	Z	None

PCS Root Type: Other Imaging (Y) vs. Computerized Tomography (2)

• Use Other Imaging (Y) when imaging is performed via OCT technology — optical coherence tomography uses near-infrared light waves, NOT ionizing radiation; it does not meet the PCS definition of CT.
• Use Computerized Tomography (2) only for traditional CT scan imaging of orbital or ocular structures — not for OCT.
• When billing 92137 in an inpatient context is truly encountered, query the current ICD-10-PCS tabular directly for the B8Y table body part values — this is an emerging procedural category and facility coding guidance for OCTA continues to develop.

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📝 Coding Examples

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Example 1 — Office: Wet AMD Monitoring, Global Billing, E/M Same Day

Clinical Scenario: A 71-year-old female with known neovascular AMD in the right eye, currently receiving intravitreal aflibercept every 8 weeks, presents for scheduled post-injection monitoring 6 weeks after her most recent injection. She reports mild improvement in central distortion. The physician performs a comprehensive established patient eye exam (VA testing, slitlamp biomicroscopy, dilated fundus evaluation with 90D lens, IOP measurement, and formal assessment of AMD severity in both eyes) and separately orders and personally interprets bilateral OCTA. The OCTA interpretation report documents a Type 1 CNV lesion of 1.8 mm² in the right subfoveal region with active flow signal; no active lesion is identified in the left eye, which shows intermediate dry AMD. The physician dictates a formal separate report referencing both structural OCT measurements and OCTA flow map findings. The physician owns and operates the OCTA equipment at the private practice location.

Field	Code	Rationale
CPT 1	92014-25	Comprehensive established patient eye exam; modifier -25 applied to the E/M code (not to 92137) — confirms a separate, medically necessary evaluation including independent AMD severity assessment, IOP, and anterior segment exam beyond the pre-imaging workup
CPT 2	92137	Global bill (PC + TC) — physician owns equipment in private practice; billed once for bilateral imaging regardless of right-eye-only active pathology
PDx	H35.3211	Exudative AMD, right eye, with active CNV — primary diagnosis driving both the clinical visit and the OCTA
SDx	H35.3122	Nonexudative AMD, left eye, intermediate dry stage — separately documented fellow-eye finding supporting bilateral imaging medical necessity

Note

Modifier -25 belongs on the E/M code (92014), not on 92137. No modifier is needed on 92137 to signal a separate service in this private practice scenario. If only the imaging (no separate E/M) was performed at this encounter, bill 92137 alone without any E/M code.

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Example 2 — Office: OCTA + Fluorescein Angiography Same Day, New CNV Evaluation

Clinical Scenario: A 67-year-old male is urgently referred for evaluation of a new subretinal lesion in the left macular area. He reports 4 days of new metamorphopsia and a central scotoma in the left eye. The physician performs a comprehensive new patient eye examination and orders both OCTA and FA on the same day: OCTA for high-resolution CNV morphologic flow mapping and lesion type classification (Type 1 vs. 2), and FA to assess leakage pattern and lesion borders to inform the decision to initiate anti-VEGF therapy. The OCTA report documents a Type 2 CNV lesion with a well-defined loop pattern and active flow signal. The FA report confirms early hyperfluorescence with late leakage consistent with active classic CNV. The physician dictates two separate interpretation reports with individually documented indications, findings, and clinical conclusions for each test.

Field	Code	Rationale
CPT 1	92004-25	Comprehensive new patient eye exam; modifier -25 on E/M for separately documented evaluation
CPT 2	92137	OCTA, bilateral, global; billed once; separately reportable from 92235 — NCCI PTP edits between 92137 and 92235 were eliminated effective Oct 1, 2025 (implementation April 1, 2026)
CPT 3	92235	Fluorescein angiography with I&R; separately reportable; modifier -59 may still be required by some commercial payers until NCCI update loads — verify payer system before omitting
PDx	H35.3221	Exudative AMD, left eye, with active CNV — index condition for the urgent referral
SDx	H35.3121	Nonexudative AMD, right eye, early dry stage — fellow eye documented at this encounter

Warning

The NCCI PTP edits between 92137 and 92235, 92240, and 92242 were eliminated effective October 1, 2025, following AAO advocacy, with CMS announcing April 1, 2026 as the quarterly NCCI update implementation date.⁵ Commercial payers and some MAC claim processing systems may not reflect this change immediately. If a 92137 + 92235 claim is denied for bundling on or after October 1, 2025, confirm the denial date and appeal citing the published NCCI edit removal. Both tests must have separately documented indications and individual interpretation reports to survive audit.

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Example 3 — Hospital Outpatient: Diabetic Retinopathy, PC/TC Split

Clinical Scenario: A 58-year-old male with T2DM on insulin (most recent A1c 9.4%) and documented bilateral severe NPDR with DME, followed at a hospital-based retina clinic, presents for bilateral OCTA evaluation prior to anticipated panretinal photocoagulation planning. The physician orders OCTA to assess retinal perfusion density, FAZ area and circularity, and extent of nonperfusion zones in the superficial and deep capillary plexuses bilaterally. The physician reviews the acquired images and dictates a detailed interpretation report documenting peripheral capillary nonperfusion involving approximately 25% of the midperipheral retina in each eye, FAZ enlargement to 0.72 mm² OD and 0.68 mm² OS, and discrete flow voids consistent with capillary dropout. The hospital owns the OCTA equipment; the physician bills interpretation only.

Field	Code	Rationale
CPT (Physician claim)	92137-26	Professional component only — physician interprets OCTA in a facility where the hospital owns the equipment; modifier -26 is required; do NOT bill the global code (no modifier) when the physician does not own the equipment
CPT (Facility claim)	92137-TC	Technical component — hospital bills for equipment, supplies, and technical staff separately under the same CPT code
PDx	E11.3413	T2DM with severe NPDR with macular edema, bilateral — most specific code when both eyes meet severe NPDR + DME criteria at this encounter; requires provider documentation of bilateral severe NPDR with edema, not inferred
SDx	E11.65	T2DM with hyperglycemia — documents metabolic context, supports medical necessity narrative, and captures HCC-adjacent documentation for risk adjustment under the diabetes code family

Note

Global period reminder: 92137 carries global period XXX — no pre- or post-procedure period applies. If a separately documented E/M was also performed at this encounter, it is reportable with modifier -25 on the E/M code. No additional modifier is required on 92137 to signal a distinct service from a same-day E/M. In the HOPD setting, PC/TC splitting is required — neither the physician nor the facility may bill the global code (no modifier) in a facility where the equipment is institutionally owned.

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⚠️ Common Coding Pitfalls

• Billing 92134 and 92137 on the same date of service: The AMA CPT 2025 parenthetical note and NCCI mutual exclusion edit prohibit reporting 92133, 92134, and 92137 at the same patient encounter. A claim with both 92137 and 92134 will deny or be downcoded to 92134. When OCTA is performed, 92137 is the sole correct code — the structural OCT component is already bundled within it. Billing 92134 separately to capture an additional component constitutes unbundling and creates recoupment exposure on audit.

• Interpretation report that lacks OCTA-specific findings: 92137 requires a physician interpretation report that explicitly documents both the structural OCT component and the OCTA angiographic flow data. A report that describes only retinal layer thicknesses, fluid volume, or edema measurements without referencing flow maps, CNV characterization, FAZ metrics, or vascular perfusion findings does not support 92137 and will be downcoded to 92134 on TPE or CERT review. The word “angiography” or specific reference to flow signal, perfusion, or CNV type must appear in the dictated report.

• Applying modifier -50 or RT/LT to 92137: 92137 is a “unilateral or bilateral” code billed once per encounter regardless of laterality. Do not apply modifier -50 (bilateral), or modifier RT + LT on separate claim lines. Doing so may trigger duplicate payment, payer edits, or overpayment that is later recouped. If a specific payer’s billing guide requests laterality information for this code, confirm the payer’s instructions directly before adding any laterality modifier not supported by the national MPFS policy.

• Billing 92137 at the same frequency as 92134: Medicare historically allowed OCT retina (92134) every 28 days for anti-VEGF monitoring. The AAO and CMS anticipate 92137 frequency limits will mirror fluorescein angiography (92235) — potentially a few times per year. Billing 92137 on the same every-28-day schedule applied to 92134 will trigger ADRs, MAC audits, and recoupment. Monitor MAC LCA publications and payer-specific frequency policies for 92137 as they are issued.⁴

• Failing to apply modifier -25 to the E/M when billing a same-day office visit: Modifier -25 must be appended to the E/M code — not to 92137 — when a physician performs a separate, medically necessary evaluation on the same date as OCTA. Claims that append -25 to the imaging code, or that lack documentation of a truly separate clinical evaluation beyond the pre-imaging workup, are frequent findings in SMRC, TPE, and CERT ophthalmology reviews. The E/M documentation must independently support the level of service billed.

• Assuming commercial payers automatically cover 92137 without prior authorization: Despite Category I CPT status effective January 1, 2025, a number of commercial payers were still categorizing 92137 as investigational or experimental through mid-2025. Practices should verify individual payer coverage status before performing OCTA, particularly for non-Medicare patients. If denial is anticipated, obtain a prior authorization or predetermination, document patient-specific informed consent regarding potential financial liability, and issue a coverage exclusion notice where required by the payer contract.

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📎 Sources

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1. AMA CPT 2025 Professional Edition — Code 92137, parenthetical notes, OCT code family revision guidance 2. AMA CPT Assistant, January 2025 — "Reporting Optical Coherence Tomography (92132-92134, 92137)" — Find-A-Code / InnoviHealth Systems 3. Repka MX, Woodke J. "New for 2025—CPT Codes 92137 for OCTA and 66683 for Iris Prosthesis Implantation." American Academy of Ophthalmology EyeNet. January 2025. https://www.aao.org/eyenet/article/92137-octa-66683-iris-prosthesis 4. American Academy of Ophthalmology — "Frequently Asked Questions Regarding CPT Code 92137 OCTA." October 2025. https://www.aao.org/practice-management/news-detail/frequently-asked-questions-cpt-code-92137-octa 5. American Academy of Ophthalmology AAOE — "Access Recent Quarter 2025 Coding Updates Curated by AAOE Experts." January 2026. https://www.aao.org/practice-management/news-detail/access-fall-2025-coding-updates-curated-by-aaoe (NCCI edit removal, 92137 × 92235/92240/92242; retroactive to Oct 1, 2025) 6. Woodke J. "2025 Ophthalmic Coding and Payment Update." Ophthalmic Professional, January 2025. https://www.ophthalmicprofessional.com/issues/2025/january/coding/ 7. Johnson MP. "2025 Ophthalmic Reimbursement Update." Review of Ophthalmology, January 10, 2025. https://www.reviewofophthalmology.com/article/2025-ophthalmic-reimbursement-update 8. Woodke J. "Retina Coding Update." ASRS Business of Retina Presentation, March 30, 2025. https://www.asrs.org/content/documents/3slides_woodke_25_3_24_retina-coding-update.pdf 9. "OCT: What to Know for 2025." Retina Today, March 2025. https://retinatoday.com/articles/2025-mar/oct-what-to-know-for-2025 10. Optos / Corcoran Consulting Group — "Ophthalmic Imaging CPT Codes and Payment Data — 2025." Updated January 2025. 11. CMS 2025 Medicare Physician Fee Schedule Final Rule (CMS-1801-FC). Federal Register, November 1, 2024. 12. CMS RVU25A Relative Value Files — 2025 MPFS; FastRVU CPT Lookup (CMS 2026 MPFS data), CPT 92137, wRVU 0.62, Total RVU 1.79 13. NCCI Policy Manual, Chapter 9 (Medicine), CMS 2024-2025; ICD-10-CM Official Guidelines for Coding and Reporting, FY2025; ICD-10-PCS Official Guidelines for Coding and Reporting, FY2025