Medicare Reimbursement for Endothelial Cell Count (Konan Medical USA)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR ENDOTHELIAL CELL COUNT
© Corcoran Consulting Group
For best results, please view in Mozilla Firefox.
Q Does Medicare cover endothelial cell count performed with a specular microscope?
A Yes, when medically necessary. Medicare has a national coverage determination policy (NCD 80.8) addressing reimbursement for endothelial cell count (ECC), also known as endothelial cell photography or specular microscopy.
Q What is Medicare’s coverage policy?
A ECC is a covered procedure under Medicare when reasonable and necessary for patients who meet one or more of the following criteria:
- Have slit lamp evidence of endothelial dystrophy (e.g., corneal guttata) (H18.51 or 371.57)*
- Have slit lamp evidence of corneal edema (H18.1-, H18.2- or 371.20 to 371.24)
- Are about to undergo a secondary intraocular lens implantation (H27.0 or 379.31)
- Have had previous intraocular surgery and require cataract surgery (e.g., Z98.83- or V45.69)
- Are about to undergo a surgical procedure associated with a higher risk to corneal endothelium, i.e., phacoemulsification or refractive surgery (subject to some limitations for excluded refractive procedures)
- Have evidence of posterior polymorphous dystrophy of the cornea (H18.58 or 371.58) or iridocorneal-endothelium syndrome (H21.26- or 364.51, H18.51 or 371.57)
- Are about to be fitted with extended wear contact lenses after intraocular surgery (H27.0- or 379.31, Z96.1 or V43.1, Z98.83 or V45.69)
* ICD-10 and ICD-9 codes, respectively. A dash (-) at the end of an ICD-10 code indicates that there are more digits to follow.
Q Are there any limitations on this policy?
A Yes. When the only visual problem is cataracts, ECC is considered to be part of the presurgical eye exam provided prior to the cataract surgery, and not separately billable. This test is not covered if performed in the preoperative evaluation for refractive keratoplasty to correct common refractive errors.
Medical coverage policies also require that ECC, as with all diagnostic tests, must have specific relevance to the individual patient and be utilized in the management of the patient’s condition. Tests must be performed by physicians qualified to use the results of the tests in caring for the patient.
Q Are there additional indications besides those noted in Medicare’s NCD?
A Yes; some individual Medicare Administrative Contractors (MACs) have published other covered indications, including visual disturbance (R48.3 or 368.16, H53.8 or 368.8) and congenital aphakia (Q12.3 or 743.35). Check your local policies; there can be considerable variation.
Q Will ECC be reimbursed if performed on the same day as an eye exam or another diagnostic test?
A Yes, subject to the limitations described above. According to Medicare’s National Correct Coding Initiative (NCCI), separate reimbursement is allowed for ECC when performed in conjunction with exams or other tests.
Q How much does Medicare allow for this test?
A Use CPT 92286 (Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis) to describe ECC. This is a bilateral service, so a single payment is made for both eyes. The 2015 national Medicare Physician Fee Schedule allowable is $39. Of this amount, $16 is assigned to the technical component and $23 is the value of the professional component (interpretation). The specific allowable for each geographic area is determined by adjusting the national rate by geographical practice cost indices.
ECC 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 How should ECC be documented in the medical record?
A In addition to the photos of the endothelium, or proof that digital images exist, the chart should contain:
- An order for the test with medical rationale
- The date of the test
- The reliability of the test (e.g., poor, due to corneal scarring)
- The test findings (e.g., number of cells/mm2 morphology)
- A diagnosis (if possible)
- The impact on treatment and prognosis
- The signature of the physician
A form suitable for documenting the interpretation of ECC and other tests is available on Corcoran’s website.
Q Is the physician’s presence required while the test is being performed?
A No. Under Medicare program standards, this test needs only general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician is not required to be present during the performance of the test.
Q How often may this test be repeated on a patient?
A There are no published limitations for repeated testing. Medicare utilization data for 2013 shows that ECC was allowed at about 0.5% of all eye exams by ophthalmologists, or approximately 5 times per 1,000 eye exams. The frequency for optometrists is slightly less.
In general, this and all diagnostic tests are covered when “medically indicated”. Clear documentation of the reason for testing is always required.
Q May we ever bill the patient directly for this test?
A Yes; sometimes a physician may feel that ECC is merited even though his or her reasons do not comport with Medicare’s coverage policies. In the situation where Medicare might not cover the test, an Advance Beneficiary Notice of Noncoverage (ABN) should be signed by the patient prior to testing. Submit your claim as 92286-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, be sure to promptly refund the patient or show why Medicare paid in error.
Provided Courtesy of Konan Medical USA (949) 521-7730
Last updated June 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.
Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com