Medicare Reimbursement for Optical Coherence Biometry (Haag-Streit)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR OPTICAL COHERENCE BIOMETRY
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Q Does Medicare pay for optical coherence biometry (OCB) using Haag-Streit’s LENSTAR®?
A Yes. Optical coherence biometry (OCB) is usually covered by Medicare subject to the limitations in its payment policies; 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.
- 92136
Add RT or LT to indicate the eye for which an IOL power was selected. Alternately, the claim can be enumerated as follows.
- 92136-TC
- 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 range 366.00-366.9 for cataract, and 743.30-743.39 for aphakia. The respective ICD-10 codes would be in the H25 through H26 and Q12 sections.
Q What documentation is required in the medical record to support claims for OCB?
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:
- an order for the test with medical rationale
- the date of the test
- biometry measurements (e.g., axial length, corneal curvature, anterior chamber depth)
- desired IOL power (i.e., interpretation)
- physician’s signature and date
An interpretation (IOL calculation) is required for each eye, generally on two different dates.
Q Is the physician’s presence required while OCB is being performed?
A Medicare hasn’t published a supervision policy for 92136. However, under the Medicare program standards, A-scan biometry 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 the second half of 2015 allows $91.27 for 92136. Of this amount, $59.65 is assigned to the technical component and $31.62 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.e.
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 rates for claims paid in 2013 show that OCB was performed 3 times more often than A-scan. Collectively, biometry was performed at 9% of office visits. That is, for every 100 exams on Medicare beneficiaries, biometry was paid 9 times.
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. Most often, the justification is an indication of progression of a chronic disease.
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. If the cataract surgery is a covered procedure, Medicare policy states: “Medicare does not routinely cover testing other than one comprehensive eye examination . . . and an A-scan or, if medically justified, a B-scan.” (Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10.1.A; CIM §35-44).
1. CMS Transmittal 105. Published 02/20/2004. Link here. Accessed 10/27/15.
Provided Courtesy of Haag-Streit USA (877) 628-1335
Last updated October 27, 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.
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