⚕️CPT Code 92223: Scanning computerized ophthalmic diagnostic imaging, quantitative analysis of complete optic nerve head

Code Description

CPT 92223 describes Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) with quantitative analysis of the complete optic nerve head. This code is typically used for glaucoma monitoring and involves technologies such as Confocal Scanning Laser Ophthalmoscopy (e.g., Heidelberg Retina Tomograph - HRT).

The procedure includes the acquisition of images, quantitative analysis of the optic nerve head parameters (e.g., cup-to-disc ratio, rim area, volume), and the physician’s interpretation and report. The CPT descriptor specifies “unilateral or bilateral,” meaning a single unit of service covers imaging of one or both eyes.^{AMA CPT 2024}

Note: 92223 is a CPT procedure code. Metrics such as wRVU and Assistant Payable status apply to procedural coding. HCC risk adjustment applies only to diagnosis codes (ICD-10-CM).

Hierarchical Condition Category (HCC)

HCC Status: Not Applicable
Reasoning: HCC (Hierarchical Condition Category) models are used for risk adjustment based on patient diagnoses (ICD-10-CM), not procedures.
Related Diagnosis Impact: While the procedure itself does not generate HCC risk, the underlying diagnosis driving the necessity of 92223 (e.g., H40.11 Primary open-angle glaucoma) carries significant HCC weight for Medicare Advantage risk adjustment. Chronic eye conditions like glaucoma are important for risk profiling.^{CMS HCC Model Documentation}

Financial & Billing Metrics

Metric	Value	Notes
wRVU	0.54	Work Relative Value Unit (2024 Medicare Physician Fee Schedule Non-Facility). Facility wRVU is typically lower (0.19).
Total RVU (Non-Fac)	1.05	Includes Work, Practice Expense, and Malpractice components in office setting.
Total RVU (Fac)	0.46	Includes Work, Practice Expense, and Malpractice components in facility setting.
Assistant Payable	No	Assistant at Surgery Indicator: 2 (Payment not allowed for assistant surgeon).
Global Period	0 Days	Diagnostic procedure; no post-operative period. E/M services may be billed separately if significant (Modifier 25).
Facility Pricing	Yes	Performed in Hospital Outpatient Departments (HOPD) and ASCs.
Non-Facility Pricing	Yes	Commonly performed in office-based imaging suites.
Bilateral Rule	Included	Code descriptor states “unilateral or bilateral”; bill once even if both eyes are imaged.^{AMA CPT 2024}

Official Coding Guidelines

Includes

Scanning computerized ophthalmic diagnostic imaging (SCODI).
Quantitative analysis of the complete optic nerve head.
Confocal scanning laser ophthalmoscopy (e.g., HRT).
Interpretation and report by the physician.
Imaging of one or both eyes (unilateral or bilateral).

Excludes / Parenthetical Notes

OCT: Do not report 92223 with 92134 (Optical Coherence Tomography) for the same eye on the same day unless distinct medical necessity is documented and payer policy allows (often bundled).
Fundus Photography: 92250 (Fundus photography) is generally considered bundled or mutually exclusive depending on payer edits if performed for the same purpose.
Optic Nerve Photos: Standard stereoscopic photos (92250) are distinct from scanning computerized imaging (92223).
Posterior Segment SCODI: 92133 is for posterior segment scanning, not specifically optic nerve head quantitative analysis.^{AMA CPT 2024}

Modifiers

-26: Professional Component (If only the interpretation is performed).
-TC: Technical Component (If only the imaging is performed).
-RT / -LT: Right Eye / Left Eye (Recommended by many payers for tracking, even if code is bilateral, to specify which eye was analyzed if only one).
-59: Distinct Procedural Service (If performed with another unrelated procedure on the same day).
-25: Significant, Separately Identifiable Evaluation and Management Service (If an E/M visit occurs on the same day as the imaging).
Note on -50: Since the descriptor includes “unilateral or bilateral,” Modifier -50 is generally not appended.^{CMS MPFS Documentation}

MS-DRG and APC Assignment

MS-DRG (Inpatient): Not Applicable
- Reasoning: MS-DRGs are assigned based on ICD-10-PCS procedure codes for inpatient hospital stays. 92223 is a CPT code used for physician/outpatient billing.
- Inpatient Equivalent: If performed inpatient, hospital coding will use ICD-10-PCS (e.g., Nuclear Medicine Imaging of Eye).
APC (Outpatient): Applicable
- System: Ambulatory Payment Classification (APC) under the Hospital Outpatient Prospective Payment System (OPPS).
- Status Indicator: Typically Status Indicator S (Significant Procedure) or Q2/Q3 depending on packaging rules.
- Associated APC: Often maps to APC 5503 (Level 3 Minor Procedures) or specific Diagnostic Imaging APCs.^{CMS OPPS Final Rule}

Code Tree (Hierarchy)

The following hierarchy illustrates the placement of 92223 within the CPT structure:

Section: Medicine
- Subsection: Ophthalmology
  - Category: Diagnostic Imaging
    - Subcategory: Scanning Computerized Ophthalmic Diagnostic Imaging
      - Code: 92223 (Quantitative analysis of complete optic nerve head)
      - Code: 92133 (SCODI posterior segment)
      - Code: 92134 (OCT posterior segment)

Coding Examples

Example 1: Glaucoma Monitoring

Scenario: A patient with established primary open-angle glaucoma returns for a 6-month follow-up. The physician orders SCODI to compare optic nerve head topography to prior scans. Both eyes are imaged.
CPT Code: 92223
ICD-10-CM: H40.119 (Primary open-angle glaucoma, unspecified eye)
Rationale: The code covers unilateral or bilateral imaging. One unit is billed.^{AAO Coding Expert}

Example 2: Professional Component Only

Scenario: A patient undergoes SCODI at a hospital outpatient department. The images are sent to the private ophthalmologist for interpretation and report only.
CPT Code: 92223--26
ICD-10-CM: H40.121 (Primary open-angle glaucoma, right eye)
Rationale: Modifier -26 indicates only the professional component (interpretation) is being billed by the physician.^{AAO Coding Expert}

Example 3: Exclusion Scenario (OCT Same Day)

Scenario: The physician performs 92223 and 92134 (OCT) on the same day for the same eye.
CPT Code: 92134 ONLY (Typically).
ICD-10-CM: H40.111 (Primary open-angle glaucoma, right eye)
Rationale: Many payers bundle 92223 into 92134 when performed on the same day as OCT provides similar or superior structural data. Documentation must support distinct medical necessity if billing both with Modifier 59.^{CMS NCCI Policy Manual}

Clinical Documentation Improvement (CDI) Tips

Medical Necessity: Document the specific reason for SCODI (e.g., “progression of glaucoma,” “baseline optic nerve topography”). Routine screening without signs/symptoms may be denied.
Interpretation: A separate, signed report detailing the quantitative analysis (e.g., rim area change, cup volume) and comparison to prior scans is required to bill 92223. The images alone are insufficient.
Technology: Ensure the technology used qualifies as SCODI (e.g., confocal scanning) rather than standard photography (92250) or OCT (92134).
Bilateral Billing: Remember that the code includes bilateral imaging. Do not bill two units or append Modifier 50 unless specific payer instructions override CPT guidelines.^{AAO Coding Expert}

92133: Scanning computerized ophthalmic diagnostic imaging, posterior segment
92134: Optical coherence tomography (OCT)
92135: Scanning computerized ophthalmic diagnostic imaging, anterior segment
92250: Fundus photography with interpretation and report
H40.11: Primary open-angle glaucoma
H40.12: Primary angle-closure glaucoma
H47.3: Other disorders of optic disc

^{AMA CPT 2024 Professional Edition} ^{CMS Medicare Physician Fee Schedule 2024} ^{CMS OPPS Final Rule 2024} ^{American Academy of Ophthalmology Coding Expert} ^{CMS HCC Risk Adjustment Model Documentation} ^{CMS NCCI Policy Manual}

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92223