Medicare Reimbursement for Endothelial Cell Count (Topcon Medical Systems)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR ENDOTHELIAL CELL COUNT
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Q Does Medicare cover endo-thelial cell count (ECC) performed with Topcon’s SP-1P specular microscope?
A Yes, when medically necessary. Medicare has a longstanding national coverage determination policy (NCD 80.8) addressing reimbursement for ECC, also known as endothelial cell photography or specular microscopy.
Q What is Medicare’s coverage policy as noted in NCD 80.8?
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 an endothelial dystrophy (e.g., corneal guttata or Fuchs endothelial dystrophy) (H18.51)
- Have slit lamp evidence of corneal edema (H18.1-, H18.2-)
- Are about to undergo a secondary intraocular lens implantation (aphakia: H27.0)
- Have had previous intraocular surgery and require cataract surgery (Z98.83-)
- 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, NCD 80.7)
- Have evidence of posterior polymorphous dystrophy of the cornea (H18.59) or iridocorneal-endothelium syndrome (H21.26-, H18.51)
- Are about to be fitted with extended wear contact lenses after intraocular surgery (aphakia: H27.0, pseudophakia: Z96.1, filtering bleb: Z98.83)
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 therefore not separately billable. This test is not covered if performed in the preoperative evaluation for refractive keratoplasty to correct 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 ordered 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 80.8?
A Some Medicare Administrative Contractors (MACs) have published other covered indications that include visual disturbance (R48.3, H53.8) and congenital aphakia (Q12.3). ICD-10 rules permit coding a symptom, sign, or less- specific condition when a diagnosis is not known. Check your local policies; they vary.
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 How should we document ECC 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)
- Comparison with prior tests (when applicable)
- A diagnosis (if possible)
- The impact on treatment and prognosis
- The signature of the physician, and date
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 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 (interpreta-tion). These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly.
92286 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 allowed with 0.4% of all eye exams by ophthalmologists. The frequency for optometrists is similar. 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 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. 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.
Provided Courtesy of Topcon Medical Systems (800) 223-1130
Last updated July 1, 2018
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, 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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