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Medicare Reimbursement for Corneal Topography (Haag-Streit)

FREQUENTLY ASKED QUESTIONS: 

MEDICARE REIMBURSEMENT FOR CORNEAL TOPOGRAPHY

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Q  Does Medicare cover corneal topography (CT)?

A  Sometimes.  Medicare covers diagnostic tests that are medically necessary according to Medicare guidelines.  Medicare does not cover routine eye exams or tests, such as those for refractive error including regular astigmatism.

 

Q  What diagnoses are typically covered and support a claim?

A  Corneal topography is most frequently used for the diagnosis and management of corneal diseases, disorders, abnormalities, or injuries.  Covered diagnoses include irregular astigmatism (H52.21- or 367.22),* keratoconus (H18.6- or 371.60), and complication of corneal graft (T85.328 or 996.51).  Check your local coverage determination (LCD) policy for additional indications.

 

Q  What documentation is required in the medical record to support claims for CT?

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:

  • order for the test with medical rationale
  • date of the test
  • the reliability of the test
  • the test findings (e.g., printout of corneal map)
  • comparison with prior tests (if applicable)
  • a diagnosis (if possible)
  • the impact on treatment and prognosis
  • physician’s signature and date

*  ICD-10 or ICD-9 codes, respectively.  A dash (-) at the end of an ICD-10 code indicates that there are more digits to follow.

 

Q  What CPT code is used to describe CT?

A  Use CPT code 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report) to report this service.

 

Q  What is the reimbursement for 92025?

A  CPT 92025 is defined as “unilateral or bilateral” so reimbursement is usually for both eyes.  The 2015 national Medicare Physician Fee Schedule allowable is $38.  Of this amount, $18 is assigned to the technical component and $20 is the value of the professional component (i.e., 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.

CT 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  Is CT bundled with other services?

A  Along with the description of 92025, CPT instructs, “Do not report 92025 in conjunction with 65710-65771”.  Medicare bundles 92025 with 65730-65770.  Medicare also bundles the technician exam, 99211, with the test.

 

Q  Must the physician be in the office while CT is performed?

A  Medicare has no supervision policy published for this diagnostic test.  In our opinion, it seems reasonable to use general supervision since most non-invasive ophthalmic tests come under that requirement.  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 often may CT be repeated?

A  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.

Within the Medicare system, in 2013, claims paid for CPT 92025 were associated with about 0.5% of all exams.  That is, for every 1,000 exams on Medicare patients, 92025 was paid 5 times.  Utilization for optometrists is much lower.  There is no utilization data on non-covered tests associated with refractive procedures or for non-Medicare payers.

 

Q  Will Medicare cover CT prior to cataract surgery?

A  Rarely.  Claims will be considered by Medicare Administrative Contractors (MACs) if there is a diagnosis, in addition to cataract, supporting medical necessity.  More often, testing with CT prior to cataract surgery is associated with planning for concurrent limbal relaxing incisions or implantation of a toric IOL, and is not covered.

 

Q  What is Medicare’s position on CT and refractive surgery?

A  Refractive surgery for the purpose of reducing dependence on eyeglasses or contact lenses is not covered by Medicare, nor are the diagnostic tests associated with this surgery, including CT.  The patient is financially responsible for the service, either as a discrete charge or as part of the refractive surgery package.  Inform the patient of their financial responsibility and get a signed Advance Beneficiary Notice of Noncoverage (ABN).  If the Medicare beneficiary requests that a claim be filed, append modifier GY to the CPT code to indicate an excluded service; be sure to link the charge to the refractive diagnosis (e.g., 367.21).

 

Q  If coverage of CT is unlikely or uncertain, how should we proceed? 

A  Explain to the patient why CT is necessary, and that Medicare or other third party payer will likely deny the claim.  Ask the patient to assume financial responsibility for the charge.  A financial waiver can take several forms, depending on insurance.

  • An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered.  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 refund the patient or show why Medicare paid in error.
  • For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
  • For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

 

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.

 

© 2015 Corcoran Consulting Group.   All rights reserved.  No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system,  without the written permission of the publisher.

 

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