Medicare Reimbursement for Corneal Topography (Visionix)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR CORNEAL TOPOGRAPHY

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Q  Does Medicare cover corneal topography (CT)?

A  Sometimes.  Medicare covers diagnostic tests that are medically necessary according to Medicare guidelines.

 

Q  What diagnoses are typically covered and support a claim?

A  CT is most frequently used for the diagnosis and management of corneal diseases, disorders, abnormalities, or injuries.  Covered diagnoses include irregular astigmatism (H52.21- or 367.22),* keratoconus (H18.6- or 371.60), and complication of corneal graft (T85.328 or 996.51).  Check your local coverage determination (LCD) policy for additional indications.

* ICD-10 or ICD-9 codes, respectively.  A dash (-) at the end of an ICD-10 code indicates that there are more digits to follow.

 

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)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • the signature of the physician

A form suitable for documenting the interpretation of CT and other tests is available on Corcoran’s website.

 

Q  What CPT code is used to describe CT?

A  CPT code 92025 is used to report this service:  “Computerized corneal topography, unilateral or bilateral, with interpretation and report”.

 

Q  What is the reimbursement for 92025?

A  CPT describes 92025 as “unilateral or bilateral” so this is billed per test and not per eye.  The first quarter 2015 national Medicare Physician Fee Schedule allowable is $38.26.  Of this amount, $17.88 is assigned to the technical component and $20.38 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  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  Must the physician be in the office when CT is performed?

A  Medicare has no supervision policy published for this diagnostic test.  In our opinion, it is 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  How often may this test 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, claims paid for CPT 92025 in CY 2013 were associated with 0.5% of all exams by ophthalmologists.  That is, for every 1000 exams on Medicare patients, 92025 was paid five times.  Utilization by optometrists is much lower.

 

Q  Will Medicare cover CT 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 CT prior to cataract surgery is associated with planning for concurrent limbal relaxing incisions or implantation of a toric IOL, and is not covered.

 

Q  May we bill the patient if Medicare doesn’t cover it?

A  Yes.  Explain to the patient in advance why the test is medically necessary, and that Medicare will likely deny the claim.  Ask the patient to assume financial responsibility for the charge; get his signature on an signed Advance Beneficiary Notice of Noncoverage (ABN) and submit your claim with modifier GA.  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.  You may not use an ABN as a way to circumvent the bundling edits with corneal transplant. 

Note that Medicare Advantage (MA) plans have their own versions of financial waiver forms that you must use for these patients instead of the ABN.

 

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.  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 his/her financial responsibility and get a signed ABN or MA waiver. 

If the Medicare beneficiary requests that a claim be filed, append modifier GY to the CPT code to indicate a statutorily excluded service; be sure to link the charge to a refractive diagnosis.

 

Provided Courtesy of Visionix Inc.  (800) 292-7468

 

Last updated January 15, 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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