Medicare Reimbursement for Corneal Topography (Topcon Medical Systems)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR CORNEAL TOPOGRAPHY

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Q: Does Medicare cover corneal topography (CT) with Topcon’s devices?

A: Corneal topography (CT) performed with Topcon’s ALADDIN, CA-800 Corneal Topographer, or the KR-1W Wavefront Analyzer is usually covered by Medicare subject to the limitations in its payment policies; other third party payers generally agree. Some of these instruments have other capabilities as well.^1,2,3

Q: What conditions are typically covered for CT?

A: Reimbursement for CT usually applies to diagnosis and management of corneal diseases, disorders, abnormalities, or injuries. Commonly covered diagnoses include irregular astigmatism (H52.21-), keratoconus (H18.6-), and complication of corneal graft (T85.328-).* Check your local policies for additional indications. Payer policies vary significantly.

Q: What documentation is required in the medical record to support a charge for CT?

A: In addition to a printout or proof that images exist, the chart should contain:

an order for the test with medical rationale
the date of the test
the reliability of the test
the test findings (e.g., printout of corneal map)
comparison with prior CT
a diagnosis (if possible)
the impact on treatment and prognosis
the signature of the physician

Document the location of the images if they are stored separately from the medical record.

Q: What CPT code describes 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 the same whether one or both eyes are tested. The 2017 national Medicare Physician Fee Schedule allowable is $38.40. Of this amount, $17.94 is assigned to the technical component and $20.46 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.
CT 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: Is CT bundled with other services?

A: Yes. CPT instructs, “Do not report 92025 in conjunction with 65710-65771”. Medicare bundles 92025 with 65730-65770. Medicare also bundles a technician exam, 99211, with CT.

Q: Must the physician be present while the CT is being performed?

A: Medicare has no supervision policy published for CT. In our opinion, it seems reasonable to use general supervision since most other 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 procedure.

Q: How often may CT 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.
Within the Medicare system, in 2015, claims paid for CPT 92025 were associated with 1% of all exams by ophthalmologists. That is, for every 100 exams on Medicare Part B patients, 92025 was paid once. This excludes CT for refractive procedures and non-covered indications. Utilization by optometrists is much lower.

Q: Will Medicare cover CT prior to cataract surgery?

A: Usually not. Claims might be paid by the Medicare Administrative Contractors (MACs) if there is a diagnosis (e.g., irregular astigmatism), in addition to cataract, to support medical necessity. More often, CT prior to cataract surgery is to screen for astigmatism and plan concurrent limbal relaxing incisions or implantation of a toric IOL when pre-existing, regular astigmatism is present. This indication is not covered.

Q: What is Medicare’s position on CT 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 diagnostic tests associated with this surgery, including CT.

Q: May I ever bill the Medicare beneficiary directly for this service?

A: Sometimes. Explain to the patient why the test 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. 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.
For non-Medicare beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing either noncovered or potentially noncovered services; MA Plans may each have their own process and waiver forms. Be sure and check.

Provided Courtesy of Topcon Medical Systems (800) 223-1130

Last updated January 01, 2017

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.

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