Medicare Reimbursement for Optical Coherence Biometry (OCULUS)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR OPTICAL COHERENCE BIOMETRY
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Q Does Medicare pay for optical coherence biometry (OCB) using OCULUS’ Pentacam® AXL?
A Yes. Medicare’s National Coverage Determination §10.1 provides for, “…a single scan to determine the appropriate pseudophakic power of the IOL…” Optical coherence biometry (OCB) is covered by Medicare subject to a few policy limitations; other third party payers generally agree.
Q What CPT code describes OCB?
A Use 92136 (Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) to report this service.
Q For an initial test with OCB, what is the claim to Medicare?
A Medicare defines OCB in an unusual way; the technical component of 92136 is a bilateral service, and the professional component is a unilateral service.1. The same is true for 76519 (A-scan with IOL power calculation). For Medicare, the initial claim for OCB is usually as follows.
Add RT or LT to indicate the eye for which an IOL power was selected. Alternately, the claim can be enumerated as follows.2.
- 92136-26 (also add RT or LT)
In either scenario, your claim indicates that both eyes were measured (technical component) but an IOL was selected for just one eye (professional component). Other payers may differ.
Q When a patient returns for second eye surgery, what then?
A Prior to the second cataract procedure, the surgeon selects the power for another IOL; additional measurements are not usually needed. The claim will read as follows.
- 92136-26 (also add RT or LT)
Q What clinical conditions support a claim for OCB testing?
A OCB is most frequently used for the diagnosis and management of cataract or aphakia. Covered diagnoses are the same as for A-scan and fall in the H25 through H26 range for cataract, and Q12 for aphakia.
Q What documentation is required in the medical record to support claims for OCB?
A Like A-scan biometry, a final written report should be included in the medical record with the following elements:
- order for the test with medical rationale
- date of the test
- biometry measurements (e.g., axial length, corneal curvature, anterior chamber depth)
- desired IOL power
- physician’s signature and date
A separate IOL calculation and interpretation is required for each eye, generally on two different dates. Medical necessity must also be documented independently for each eye.
Q Is the physician’s presence required while OCB is being performed?
A Medicare hasn’t published a super-vision policy for 92136. However, under the Medicare program standards, a similar procedure, A-scan biometry, 76519, needs only 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 How much does Medicare allow for this test?
A The national Medicare Physician Fee Schedule for 2016 allows $91 for 92136. Of this amount, $59 is assigned to the technical component and $32 is the value of the professional component. These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.
92136 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 frequently is OCB performed?
A The frequency of OCB is linked to cataract surgery. CMS utilization data for claims paid in 2014 shows that 92136 was performed at 7% of office visits. That is, for every 100 exams on Medicare beneficiaries, optical coherence biometry was paid 7 times. Relative to A-scan, 76519, OCB was 4 times more frequent.
Q How often may OCB be repeated?
A Repeated biometry is indicated when there is reason to distrust an earlier measurement. For example, a prior IOL calculation lead to an undesirable outcome, or the earlier measurement was made a long time ago (>12 months).
In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required.
Q If we perform both OCB and A-scan biometry prior to cataract surgery with IOL, may we be reimbursed for both?
A No. One of the tests is duplicative and NCCI edits preclude payment for both tests.
1. CMS Transmittal 105. 1st Update to the 2004 MPFS Database. Published 02/20/2004. Link here. Accessed 02/19/16.
2. Note that some Medicare contractors do not want eye modifiers on these claims; check with your local payer.
Provided Courtesy of OCULUS, Inc. (888) 284-8004
Last updated May 2, 2016
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.
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