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Reimbursement for the i.Profilerplus by ZEISS

FREQUENTLY ASKED QUESTIONS: 

REIMBURSEMENT FOR THE i.Profilerplus® BY ZEISS

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Q  What is the i.Profilerplus® by ZEISS?

A  The i.Profilerplus instrument provides computerized corneal topography (CCT), keratometry, auto-refraction, and wavefront aberrometry in a single sitting.  The instrument is designed for tabletop use in the office.

 

Q  What documentation is required in the medical record to support a charge for these three tests?

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

 

Q  What CPT code describes wavefront aberrometry and refraction?

A  CPT 92015 is defined as determination of the refractive power of the eye.  When a typical refraction is done, use CPT 92015 to denote the service.  Wavefront aberrometry is more involved when the provider uses the wavefront information in the treatment of the patient.  In CPT, the use of modifier -22 signifies “increased procedural services” and should be considered in the context of this “super-refraction”; file the claim as 92015-22.  When aberrometry alone, or refraction and aberrometry are done on the same date, file a claim for a single service of 92015.

 

Q  When is wavefront aberrometry indicated, and how can results be shown?

A  Aberrometry is useful when patient complaints are vague and an eye exam does not fully explain the symptoms; it is also helpful after cornea- and lens-based surgery.  The wavefront data can be further analyzed for lower vs. higher and corneal vs. total wavefronts. The display can also show root mean square (RMS), point spread function (PSF), and modulation transfer function (MTF), and the patient’s personal result via an aberrated E.

 

Q  What CPT code is used to describe CCT with the i.Profilerplus?

A  CPT code 92025 has been in effect since January 1, 2007 to report this service:  “Computerized corneal topography, unilateral or bilateral, with interpretation and report”.  Keratometry is not separately billable; it is integral to CCT.

 

Q  Does Medicare cover CCT and if so, for what indications?

A  CCT is sometimes covered; the usual diagnoses are cornea-related.  Commonly covered diagnoses include irregular astigmatism (H52.21- or 367.22),* keratoconus (H18.6- or 371.60), and complications of corneal grafts (T85.328 or 996.51).  Check your local coverage determination (LCD) policy for additional indications or restrictions.  Most other indications will be non-covered.  Some plans allow the patient to pay.

*  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 is Medicare’s position on corneal topography as it relates to 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, such as corneal topography.  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 Advance Beneficiary Notice of Noncoverage (ABN).  If a Medicare beneficiary requests that a claim be filed, append modifier -GY to indicate an excluded service; be sure to link the charge to the refractive diagnosis.  For other patients, a Notice of Exclusion from Health Plan Benefits (NEHB) serves the same purpose.

 

Q  How are refractive services reimbursed?

A  Medicare1. and most third party payers do not cover refractive services such as wavefront aberrometry and refraction.  Instead, educate patients regarding this option and their financial responsibility.  Payment should be collected at the time of service.

 

Q  Is it possible to bill for more than one test on the same day?

A  Yes.  Multiple tests may occur and be charged on the same day, as long as there is sufficient justification for each service and the services are not duplicative, bundled, or mutually exclusive.  Additionally, patients may have several co-morbidities that warrant investigation.

 

Q  What is the reimbursement for these services with the i.Profilerplus?

A  In the first half of 2015, the national Medicare Physician Fee Schedule allowable for 92025 is is $38.26; of this, $17.88 is assigned to the technical component (-TC) and $20.38 to the professional portion (-26, or interpretation).  These values are modified by local wage indices, so actual payments vary.

Although it is not covered, Medicare assigns RVUs to 92015.  As of this writing, the Medicare value is $20.  Nationally, private fees vary widely ($25-$90).

 

Q  Are these tests bundled with any other services?

A  Medicare’s National Correct Coding Initiative (NCCI) does not bundle 92015 with any ophthalmic services.  For corneal topography, CPT instructs, “Do not report 92025 in conjunction with 65710-65771”.  Other payers may have different bundles; check the payer policies.

 

1.  Medicare Benefit Policy Manual, Chapter 16 §90, p 26.  Link here. Accessed 06/04/15.

 

Provided Courtesy of ZEISS  (800) 358-8258

 

Last updated June 5, 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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