Medicare Reimbursement for Corneal Pachymetry (Accutome)

FREQUENTLY ASKED QUESTIONS: 

 MEDICARE REIMBURSEMENT FOR CORNEAL PACHYMETRY

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Q  What is corneal pachymetry?

A  Corneal pachymetry is a measurement of the thickness of the cornea.  The normal human cornea is approximately 550 microns thick centrally and a full millimeter thick peripherally.  A pachymeter is used to measure the central cornea, although there are diseases that warrant a patchette or pachymetry grid across a wide area.  Accutome’s AccuPach VI and PachPen use ophthalmic ultrasound to perform corneal pachymetry.

 

Q  What are the indications for corneal pachymetry?

A  Pachymetry may be ordered when a diseased cornea is edematous or ectatic, and when planning corneal refractive surgery.  The Ocular Hypertension Treatment Study (2002) revealed that corneal thickness plays a significant role in glaucoma.  Applanation tonometry of an unusually thin cornea results in a falsely low IOP reading because the resistance of the cornea is less than expected.  The reverse is also true; thicker corneas yield falsely high IOP values.

 

Q  What CPT code describes corneal pachymetry by ultrasound?

A  CPT code 76514 (Ophthalmic ultra-sound, diagnostic; corneal pachymetry, unilateral or bilateral, determination of corneal thickness) should be used to report this test.  It is not appropriate to report 76514 when optical pachymetry is performed. 

 

Q  What documentation is required to support a claim for corneal pachymetry?

A  Like other ophthalmic tests, the medical record should include:

  • order for the test with medical rationale
  • date of the test
  • test findings (e.g., corneal thickness measurements)
  • comparison with prior tests (if applicable)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • the physician’s signature

 

Q  Does Medicare cover corneal pachymetry?

A  Yes, many Medicare Administrative Contractors (MACs) have published local coverage determination (LCD) policies for corneal pachymetry by ultrasound.  Most published LCDs indicate that corneal pachymetry for glaucoma is covered once in a patient’s lifetime unless there has been interval corneal trauma or surgery.  Reimbursement is also available for a variety of corneal diseases. 

 

Q  Is the physician’s presence required while pachymetry is being performed?

A  Under Medicare program standards, this test requires 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  How much does Medicare allow for corneal pachymetry?

A  76514 is defined as “unilateral or bilateral” so reimbursement is usually for both eyes.  The 2015 Medicare Physician Fee Schedule allowable for 76514 is $15.  This includes $5 for the technical component and $10 for the professional component (i.e., interpretation).  These amounts are adjusted in each area by local wage indices.  Other payers set their own rates.

Corneal pachymetry is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR).  This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day. 

 

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

A  Explain to the patient why pachymetry 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  How frequently is this test performed?

A  The Medicare utilization rate for claims paid in 2013 shows that pachymetry was performed in 2% of all office visits by ophthalmologists.  That is, for every 100 exams performed on Medicare beneficiaries, Medicare paid for this service 2 times.  For optometrists, the utilization rate is slightly lower.

 

 

Provided Courtesy of Accutome Inc.  (800) 979-2020

 

Last updated July 1, 2015

 

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.

 

© 2015 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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