Reimbursement for Tests with the OCULUS Keratograph 5M (OCULUS)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR TESTS WITH THE OCULUS KERATOGRAPH 5M
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Q What tests can be performed with the OCULUS Keratograph 5M®?
A The Keratograph 5M is a multipurpose diagnostic instrument for evaluating the anterior segment using topography, photography, and other imaging. The instrument can perform multiple tests, including:
- Corneal topography (CPT 92025)
- External ocular photography (CPT 92285)
- Pupillometry (92499)
- Tear meniscus height (part of 0330T)
- Lipid layer thickness (part of 0330T)
- Meibomian gland imaging (CPT 0507T)
- Zernike and Fourier analysis of the cornea
- Keratometry (part of an eye exam)
- Tear film break-up time (part of an eye exam)
- Cornea/sclera elevation (part of CL service)
- Oxi-Map (part of CL service)
These tests supplement the physician’s evaluation and management of corneal and lacrimal disease, planning for anterior segment surgery, and contact lens fitting. Some features of the Keratograph 5M are particularly useful for patient education.
Q Does Medicare cover corneal topography (CT) and external ocular photography?
A Yes, but since no national Medicare policy exists for either test, coverage is at the discretion of each Medicare contractor.
Q Does Medicare cover 0330T, 0507T and 92499?
A Maybe; Category III codes usually don’t have coverage policies; check your payers.
Q Does Medicare cover Zernike and Fourier analysis?
A No. These are refractive in nature; although they exceed the familiar sphere, cylinder and axis that is commonly found in refraction (CPT 92015). Refraction is not covered by Medicare. Nonetheless, they are additive with the basic service, and deserve an additional charge.
Q Does Medicare cover contact lens fitting?
A Contact lens fitting for routine refractive error not associated with aphakia or pseudophakia is not covered. Contact lens fitting for keratoconus (CPT 92072) may be covered.
Q Are any of these other tests covered by Medicare?
A The other tests shown in Q#1, not already discussed, are incidental to other services and are not separately billable. They do have significant patient educational value.
Q What are Medicare’s reimbursement rates?
A In 2021, the national Medicare Physician Fee Schedule allows $23 for 92285; $20 is assigned to the technical component, and $3 for the professional component. For 92025, the allowable amounts are $37, $18 and $20, respectively (rounded). Category III codes and unspecified do not have MPFS allowed amounts; if covered, payment is at the discretion of the payer.
Q What documentation is required in the medical record?
A In addition to the images, the chart should contain:
- order for the test with medical rationale
- date of the test
- the reliability of the test (e.g., unstable tear film)
- test findings (e.g., irregular astigmatism due to worsening keratoconus)
- comparison with prior tests
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the signature of the physician
Document the location of the images if they are stored separately from the medical record.
Q Is it possible to bill for more than one test on the same day?
A Yes. Multiple tests may occur and be billed on the same day as long as there is sufficient justification for each service and the services are not duplicative, bundled, or mutually exclusive. For instance, assessing different parts of the eye using different tests is one justification, as occurs when corneal topography is performed concurrent with external photography. Additionally, patients may have several co-morbidities that warrant investigation using different tests.
92025 and 92285 are 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 frequently may tests with the OCULUS Keratograph 5M be performed?
A Generally, tests may be repeated as often as is medical necessary. Some reasons are:
- During the eye exam that precedes the order for a repeat test, the physician suspects that the patient’s condition has changed for the worse due to:
- objective evidence of vision loss
- new symptoms or complaints
- a recent surgical intervention
- exam findings of disease progression
- Earlier tests are no longer reliable.
- The AAO’s Preferred Practice Patterns may suggest repeat testing at specific intervals which vary based on the disease progression.
Q If coverage of a test is unlikely or uncertain, how should we proceed?
A Explain the necessity and that the claim will likely be denied. Ask the patient to assume financial responsibility for the charge.
- 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 OCULUS, Inc. (888) 284-8004
Last updated March 11, 2021
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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