Medicare Reimbursement for Optical Coherence Biometry (Zeiss)

FREQUENTLY ASKED QUESTIONS:

MEDICARE REIMBURSEMENT FOR OPTICAL COHERENCE BIOMETRY

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Q: Does Medicare pay for optical coherence biometry (OCB) using Carl Zeiss Meditec’s IOL Master?

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

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 through H26 series for cataract and the Q12 series for aphakia.

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

A: In addition to the OCB printout, 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 dateAn interpretation (IOL calculation) is required for each eye, generally on two different dates. Remember to date and sign the interpretation.

An interpretation (IOL calculation) is required for each eye, generally on two different dates. Remember to date and sign the interpretation.

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: 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

Add RT or LT to indicate the eye for which an IOL power was selected.² 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). Other payers may differ.
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: Some Medicare contractors do not want modifiers RT or LT on these claims; check your local policy.

Q: How much does Medicare allow for this test?

A: The 2019 national Medicare Physician Fee Schedule allowable for 92136 is $71.36. Of this amount, $39.28 is assigned to the technical component and $32.07 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 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 2017 show that biometry with IOL calculation (92136 and 76519) was associated with 9% of all office visits. That is, for every 100 exams on Medicare beneficiaries, biometry was paid 9 times. OCB constituted almost 90% of the total.

Q: Will Medicare cover repeat testing?

A: Sometimes. 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).

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 ZEISS

Last updated May 13, 2019

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. CPT is a registered trademark of the American Medical Association.

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