Medicare Reimbursement for Optical Corneal Pachymetry (Visionix)
FREQUENTLY ASKED QUESTIONS:
MEDICARE REIMBURSEMENT FOR OPTICAL CORNEAL PACHYMETRY
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Q What is corneal pachymetry?
A Corneal pachymetry is a measurement of the thickness of the cornea. In general, the normal human cornea is approximately 550 microns thick centrally and a millimeter thick peripherally. A pachymeter is most often used to measure the central cornea, although there are diseases that warrant multiple or off-center measurements.
Q What are the indications for corneal pachymetry?
A Pachymetry is customarily ordered when a diseased cornea is edematous or ectatic, and may be used when planning corneal refractive surgery. An important 2002 study revealed that corneal thickness plays a significant role in glaucoma (Ocular Hypertension Treatment Study). Applanation tonometry of an unusually thin cornea results in a falsely low IOP reading because the resistance of the cornea is less than expected. The reverse is also true; thicker corneas yield falsely high IOP values.
Q What CPT code describes optical corneal pachymetry?
A The Visionix VX-120 uses optical technology to measure corneal thickness, so CPT code 76514 (Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral, determination of corneal thickness) does not apply. Instead, CPT instructs billers to use 92499 (Unlisted ophthalmological service or procedure) when no listed code applies.
Q Does Medicare cover corneal pachymetry?
A Yes, many Medicare Administrative Contractors (MACs) have published local coverage determination (LCD) policies for corneal pachymetry using ultrasound (CPT 76514). Most published LCDs indicate that corneal pachymetry is covered once in a patient’s lifetime when done for glaucoma or glaucoma suspect. Patients with ectatic corneal diseases are generally covered; repeat pachymetry is covered when medically necessary.
There is currently no national Medicare coverage policy for corneal pachymetry, so check your LCDs. Further, there is no coverage policy for optical corneal pachymetry (92499) and claims for reimbursement using this code face administrative obstacles.
Q If Medicare doesn’t cover it, may I charge the patient?
A Yes. Explain to the patient why the test is necessary, and that Medicare will likely deny the claim. Ask the patient to assume financial responsibility for the charge and get his/her signature on an Advance Beneficiary Notice of Noncoverage (ABN) prior to performing the test. 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 re-fund the patient or show why Medicare paid in error.
Note that Medicare Advantage (MA) plans have their own versions of financial waiver forms that you must use for these patients instead of the ABN.
Q How much does Medicare allow for optical corneal pachymetry?
A CPT 92499 is not assigned RVUs within the Medicare Physician Fee Schedule (MPFS), so there is no fixed allowed amount. Corneal pachymetry by ultrasound (76514) is allowed about $15 in the first quarter 2015 MPFS. It is defined as “unilateral or bilateral” so reimbursement is per test, not per eye.
Q What is Medicare’s supervision requirement for this test?
A There are no published supervision requirements for 92499, however 76514 requires 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 test. In our opinion, it is reasonable to apply the same logic to optical corneal pachymetry.
Q How frequently is corneal pachymetry performed?
A Within the Medicare system, claims paid for CPT 76514 in CY 2013 were associated with about 2% of all exams by ophthalmologists. That is, for every 100 exams on Medicare patients, 76514 was paid twice. Utilization by optometrists is much lower. Unfortunately, there is no utilization data for optical corneal pachymetry (92499).
Q What documentation is required to support a claim for corneal pachymetry?
A Like other ophthalmic tests, the medical record should include:
- order for the test with medical rationale
- date of the test
- the reliability of the test
- test findings (i.e., corneal thickness measurements)
- a diagnosis (if possible)
- the impact on treatment and prognosis
- the physician’s signature
Provided Courtesy of Visionix Inc. (800) 292-7468
Last updated December 11, 2014
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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