Medicare Reimbursement for Corneal Hysteresis (Reichert & AMETEK)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR CORNEAL HYSTERESIS

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Q  What is hysteresis?

Hysteresis is a measurement that characterizes response to application and removal of force (load/unload).  The term is used to describe materials or systems that do not instantly follow forces applied to them but react slowly, or dissipate a portion of the applied energy.  While the term is frequently used in physics and engineering, there are more than 7,500 published papers on hysteresis in a variety of medical fields.1.

 

Q  Why measure corneal hysteresis?

A  Measuring the biomechanical properties of the cornea with Reichert’s Ocular Response Analyzer® enables ophthalmologists, optometrists, and researchers to quantify various corneal conditions.  Low corneal hysteresis (CH) demonstrates that the cornea is less capable of absorbing (damping) the energy of an air pulse.  Clinical studies suggest that a low CH measurement may indicate ocular abnormalities or eyes at risk for disease.2., 3., 4.

 

Q  What are the indications for CH testing?

A  The device FDA 510(k) states that the indications for use are for the measurement of intraocular pressure and the corneal biomechanical response.  The most common clinical application of the CH measurement is the diagnosis and monitoring of glaucoma.5., 6.  Additionally, the CH measurement provides information which may be useful in identification of corneal pathology or pre-refractive surgery risk assessment.

 

Q  What CPT code is used to report measurement of corneal hysteresis?

A  As of January 1, 2015, CPT 92145 should be used to report this test.

92145   Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report. 

This Category I CPT code replaced the Category III CPT code, 0181T, introduced July 1, 2007.

 

Q  What is the Medicare reimbursement for this test?

A  CPT 92145 is defined as “unilateral or bilateral” so reimbursement is usually for both eyes.  The 2016 national Medicare Physician Fee Schedule allowable for 92145 is $16.  This includes $7 for the technical component and $9 for the professional component (i.e., interpretation).  These amounts are adjusted in each area by local wage indices.  Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

 

Q  Will Medicare and other third-party payers cover CH testing?

A  Sometimes.  In the absence of a published policy, coverage is determined on a case-by-case basis at the discretion of the payer.  Some payers have published policies that declare CH is “experimental and investigational” and consequently not covered.7., 8.

 

Q  If coverage of corneal hysteresis is unlikely or uncertain, how should we proceed? 

A  Explain to the patient why corneal hysteresis is necessary, and that Medicare or other third party payer will likely deny the claim.  Ask the patient to assume financial responsibility for the charge.  A financial waiver can take several forms, depending on insurance.

  • An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered.  You may collect your fee from the patient at the time of service or wait for a Medicare denial.  If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
  • For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
  • For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

 

Q  What documentation is required in the medical record for CH testing?

A  In addition to the results of the test, the medical record should contain:

  • Patient’s name and date of test
  • Order for the test with medical rationale
  • Reliability of the test
  • Test findings  (i.e., printout)
  • Assessment, diagnosis
  • Comparison with prior tests (if available)
  • Impact on treatment, prognosis
  • Physician’s signature

 

Q  How frequently may CH testing be repeated?

A  There are no published limitations for repeated testing.  In general, this and all diagnostic tests are reimbursed when medically indicated.  Clear documentation of the reason for testing is always required.  Too-frequent testing can garner unwanted attention from Medicare and other third party payers.

 

Q  Must the physician be in the office while CH testing is being performed?

A  Under Medicare program standards, this test requires only general supervision.  General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

 

Q  Is CH testing bundled with other services?

A  Yes.  According to Medicare’s National Correct Coding Initiative (NCCI), 92145 is bundled with the CPT code 92140, E/M code 99211, and HCPCS codes G0117 and G0118.

 

1.     PubMed.  Search for term “hysteresis”

2.     Deol, M, Taylor, DA, Radcliffe, N.  Corneal hysteresis and its relevance to glaucoma.  Curr Opinion Ophthalmol.  Mar 2015.  Vol 26 No 2.  Mar 2015. 

3.     Shah, S, et al.  Assessment of the Biomech Properties of the Cornea with the Ocular Response Analyzer in Normal and Keratoconic Eyes.  Invest Ophthalmol & Vis Sci.  July 2007.  Vol 48 No 7 p. 3026-3031. 

4.     del Buey, MA, et al.  Biomechanical Properties of the Cornea in Fuchs’ Corneal DystrophyInvest Ophthalmol & Vis Sci.  July 2007.  Vol 50 No 7 p. 3199-3202.

5.     FDA.  Clearance letter, K032799.  2004. 

6.     FDA.  Clearance letter, K081756.  2008. 

7.     United Health Care.  Clinical Policy 048.9 T2

8.    Aetna.  Glaucoma Testing Policy 0622

 

Provided Courtesy of Reichert Inc. & AMETEK Inc.  (888) 849-8955

 

Last updated March 2, 2016

 

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers.  This document is not an official source nor is it a complete guide on reimbursement.  The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

 

© 2016 Corcoran Consulting Group.   All rights reserved.  No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system,  without the written permission of the publisher.

 

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