Medicare Reimbursement for Corneal Topography
FREQUENTLY ASKED QUESTIONS
Medicare Reimbursement for Corneal Topography
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q: What is corneal topography performed with Medmont E300 distributed by Nidek?
A: Corneal topography is a non-invasive imaging technique for mapping the surface curvature of the cornea.1
Q: What diagnoses are typically covered and support a claim?
A: Corneal topography is most frequently used for the diagnosis and management of corneal diseases, disorders, abnormalities, or injuries. Covered diagnoses include irregular astigmatism (H52.21-), keratoconus (H18.6-), and complications of corneal graft (T85.328). Check your local cover-age determination (LCDs) for additional indications.
Medicare covers diagnostic tests that are medically necessary according to Medicare guidelines. Medicare does not cover routine eye exams or tests, such as those for refractive error including regular astigmatism.
Q: What documentation is required in the medical record?
A: A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images or a reference to where they are stored, the medical record should include:
- order for the test with medical rationale
- date of the test
- the reliability of the test (if compromised)
- test findings (e.g., printout of corneal map)
- comparison with prior tests (if applicable)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- physician’s signature and date
Q: What CPT code is used to describe this test?
A: Use CPT code 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report) to report this service.
Q: What is the reimbursement for 92025?
A: CPT 92025 is defined as “unilateral or bilateral” so reimbursement is for one or both eyes. The 2018 national Medicare Physician Fee Schedule allowable is $38.88. Of this amount, $18.36 is assigned to the technical component and $20.52 is the value of 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.
Corneal topography 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: Must the physician be in the office while corneal topography is being performed?
A: Medicare has no supervision policy published for this diagnostic test. In our opinion, it seems reasonable to use general supervision since most non-invasive ophthalmic tests come under that requirement. 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 test.
Q: Is corneal topography bundled with other services?
A: Along with the description of 92025, CPT instructs, “Do not report 92025 in conjunction with 65710-65771”. Medicare bundles 92025 with 65730-65770. Medicare also bundles the technician exam, 99211, with the test.
Q: How often may this test be repeated?
A: In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.
In 2016, CMS utilization of CPT 92025 was 0.8%. That is, for every 1,000 exams on Medicare patients, 92025 was paid 8 times. Utilization for optometrists is about 0.3%. There is no utilization data on non-covered tests associated with refractive procedures or for non-Medicare payers.
Q: What is Medicare’s position on corneal topography and refractive surgery?
A: Refractive surgery for the purpose of reducing dependence on eyeglasses or contact lenses is not covered by Medicare, nor are the associated diagnostic tests, including corneal topography (NCD §80.7). The patient is financially responsible for the service, either as a discrete charge or as part of the refractive surgery package. Inform the patient of their financial responsibility. If a Medicare beneficiary requests that a claim be filed, append modifier GY to the CPT code to indicate an excluded service; be sure to link the charge to the refractive diagnosis (i.e., H52.22-).
Q: Will Medicare cover corneal topography prior to cataract surgery?
A: Rarely. Claims will be considered by Medicare Administrative Contractors (MACs) if there is a diagnosis, in addition to cataract, supporting medical necessity. More often, testing with corneal topography prior to cataract surgery is associated with planning for concurrent limbal relaxing incisions or implantation of a toric IOL, and is not covered.
Q: If coverage of corneal topography is unlikely or uncertain, how should we proceed?
A: Explain why corneal topography is necessary, and that Medicare or other payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms.
- 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 have their own waiver processes and are not permitted to use the Medicare ABN form.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
1 Wikipedia. Corneal Topography. Retrieved 03/27/18.
Provided Courtesy of Nidek (800) 223-9044
Last updated May 2, 2018
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including 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.
© 2018 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. CPT is a registered trademark of the American Medical Association.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com