Medicare Reimbursement for Optical Coherence Biometry (Nidek)

FREQUENTLY ASKED QUESTIONS:

Medicare Reimbursement for Optical Coherence Biometry

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Q: Does Medicare pay for optical coherence biometry (OCB) using Nidek’s AL-Scan Optical Biometer?

A: Yes. OCB is covered by Medicare subject to the limitations in its payment policies; other third party payers generally agree.

The AL-Scan also performs other measurements which are incidental in the context of IOL calculations. The instrument has 3-D auto-tracking as well for greater accuracy.

Q: What clinical conditions support a claim for OCB testing?

A: OCB is most frequently used prior to lens surgery to select an IOL for patients with cataract or aphakia. The ICD-10 diagnosis codes would be in the H25- to H26- series for cataract, H27.0- for aphakia, and the Q12- series for con-genital aphakia.

Q: What documentation is required in the medical record to support a claim for OCB?

A: In addition to the OCB printout or a reference to where electronic records are stored, the chart should contain:

an order for the test with medical rationale
the date of the test
reliability of the test
biometry measurements (e.g., axial length, corneal curvature, anterior chamber depth)
documentation of the selection of the desired IOL power (i.e., interpretation)
the signature of the physician, and date

An interpretation (IOL calculation) is required for each eye, generally on two different dates. Date and sign the interpretation or print-out.

Q: How do we submit 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 (also add RT or LT)

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 (i.e., technical component) but an IOL was selected for just one eye (i.e, professional component).
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)

Note that some Medicare contractors do not want modifiers RT or LT on these claims; check your local policy.
Many payers follow the Medicare payment method, but not all. Check payer instructions.

Q: How much does Medicare allow for this test?

A: The 2018 national Medicare Physician Fee Schedule allowable for 92136 is $80.28. Of this amount, $48.24 is assigned to the technical component and $32.04 is the value of the professional component (interpretation). 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 on the ophthalmology MPPR list is done 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 2016 show that biometry with IOL calculation (92136 and 76519) was associated with 10% of all office visits. That is, for every 100 exams for Medicare beneficiaries, biometry was paid 10 times. OCB constituted roughly 80% of these tests.

Q: Will Medicare cover repeat testing?

A: Sometimes. Repeated biometry is indicated when there is reason to distrust an earlier measurement. For example: an earlier measurement was made a long time ago (>12 months); a prior IOL calculation lead to an undesirable out-come; or the axial length may have changed (e.g., scleral buckling to repair retinal detachment).

Q: Must the physician be present while this test is being performed?

A: Medicare hasn’t published a super-vision policy for 92136, so we looked at A-scan biometry for guidance. Under 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. We believe this is appropriate for OCB.

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. Nor may you bill the patient for the additional test. 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).

Select the code based on the test that was used for the IOL power selection.

¹ CMS Transmittal 105 (February 20, 2004), effective retroactively to January 1, 2004. Link here.

Provided Courtesy of Nidek (800) 223-9044

Last updated May 10, 2018

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including 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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