Medicare Reimbursement for Endothelial Cell Count

FREQUENTLY ASKED QUESTIONS

Medicare Reimbursement for Endothelial Cell Count

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Q:  Does Medicare cover endothelial cell count performed with Nidek’s CEM-530 specular microscope?

A:  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.
ECC is a covered procedure under Medicare when reasonable and necessary for patients who meet one or more of the following criteria:

  1. Have slit lamp evidence of endothelial dystrophy (e.g., corneal guttata, H18.51)
  2. Have slit lamp evidence of corneal edema (H18.1-, H18.2-)
  3. Are about to undergo a secondary intraocular lens implantation (H27.0)
  4. Have had previous intraocular surgery and require cataract surgery (e.g., Z98.83-)
  5. 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)
  6. Have evidence of posterior polymorphous dystrophy of the cornea (H18.58) or iridocorneal-endothelium syndrome (H21.26-, H18.51)
  7. Are about to be fitted with extended wear contact lenses after intraocular surgery (H27.0-, Z96.1, Z98.83)

Some individual Medicare Administrative Contrac-tors (MACs) have published other covered indications, including visual disturbance (R48.3, H53.8) and congenital aphakia (Q12.3). Check your local policies.

 

Q:  Are there any limitations on coverage?

A:  Yes. When the only visual problem is cataracts, ECC is considered to be part of the presurgical eye exam and not separately billable (per NCD §80.8 and §10.1). This test is also 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 not ordered by the physician who is treating the beneficiary are not reasonable and necessary.”1

 

Q:  Is the physician’s presence required while the test 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:  Will ECC be reimbursed if performed on the same day as an eye exam or another diagnostic test?

A:  Yes, subject to the limitations noted above. According to Medicare’s National Correct Coding Initiative (NCCI), separate reimbursement is allowed for ECC when performed in conjunction with exams (except technician exam, 99211) or other tests.

 

Q:  What documentation is required in the medical record to support claims for ECC?

A:  A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images, the medical record should include:

  • order for the test with medical rationale
  • date of the test
  • reliability of the test (e.g., poor, due to corneal scarring)
  • test findings (e.g., number of cells/mm2 morphology)
  • comparison with prior tests (if applicable)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • physician’s signature

 

Q:  How much does Medicare allow for this test?

A:  CPT code 92286 (Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis) describes ECC. This is a bilateral service, so a single payment is made for both eyes. The 2018 national Medicare Physician Fee Schedule allowable is $39.24. Of this amount, $16.56 is assigned to the technical component and $22.68 is the value of the professional component (interpretation). The specific allowable for each geographic area is adjusted by local 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 often may this test be repeated on a patient?

A:  There are no published limitations for repeated testing. Medicare utilization data for 2016 shows that ECC was associated with 0.4% of all eye exams by optometrists and ophthalmologists, or approximately 4 times per 1,000 eye exams. 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 corneal disease.

 

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

A:  Explain why ECC 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 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 42 CFR §410.32. Medicare diagnostic test policy. Accessed 03/27/18.

 

Provided Courtesy of Nidek  (800) 223-9044

Last updated April 24, 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.

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