Ophthalmology/Optometry

Local Coverage Determinations

Table of Contents

Coverage

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Cataract Extraction LCD L33558

A cataract is an opacity or cloudiness in the lens of the eye(s), blocking the passage of light through the lens, sometimes resulting in impaired vision. Cataract development occurs in 60% of adults 65 years of age or greater. There are multiple factors associated with cataract development. Some causes of cataracts may include ultraviolet-β radiation exposure, complications of diabetes, drug and/or alcohol use, smoking and the natural process of aging. Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). This LCD defines coverage and describes criteria necessary to justify the performance of cataract extraction(s) or other select lensectomies.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

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Corneal Pachymetry LCD L33630

Corneal pachymetry is the measurement of corneal thickness and commonly uses either ultrasonic or optical methods. Measurement of corneal thickness in individuals presenting with increased intraocular pressure assists in determining if there is a risk of glaucoma or if the individual's increased eye pressure is the result of abnormal corneal thickness. The test must be integral to the medical management decision-making of the patient. Coverage is limited to ophthalmologists and optometrists.

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Coding Guidelines

CPT code 92499 (unlisted ophthalmological service or procedure) should be used to report optical pachymetry services. The phrase, “optical pachymetry” should be listed in the narrative note in item 19 of the CMS-1500 form or electronic equivalent for claims submitted to Part B and in FL 80 for claims submitted to Part A. The optical pachymetry service should be billed and is valued equivalently to the ultrasonic service (CPT code 76514). Modifier RT, LT or 50 (bilateral) should be reported with CPT code 92499, as appropriate.

CPT code 76514 is reimbursed as a bilateral service (both eyes are included in a single test). Therefore, it should be billed once (one unit of service) regardless of whether it was performed on one or two eyes. If the service is performed unilaterally, report modifier RT or LT and modifier 52 (reduced services) on the claim.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

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Ophthalmic Biometry for Intraocular Lens Power Calculation LCD L33621

There are two methods used for intraocular lens power calculation:

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A-Scan Ultrasound Ophthalmic Biometry

Ophthalmic A-scan biometry by ultrasound echography is performed through the optical axis of the eye to determine the power of an IOL lens implant. The technical portion of ophthalmic biometry is usually performed in both eyes at the same setting.

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Nonultrasound Ophthalmic Biometry

OCB utilizes partial coherence interferometry for measuring axial length (biometry) and for intraocular lens power calculation when planning for cataract surgery. OCB also measures the corneal curvature and anterior chamber depth. The technical portion is usually performed in both eyes at the same visit.

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Coding Guidelines

Currently, the MPFSDB bilateral surgery indicator is “2” for the global and technical components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of “2” is as follows:

  • 2 = 150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.

When the MPFSDB bilateral surgery indicator is “2‚” the RVUs are based on the procedure performed on each eye.

  • The global service includes the bilateral technical component (76519-TC or 92136-TC) and a unilateral professional service (76519-26 or 92136-26). The anatomic modifier (RT or LT) should be used to indicate the eye on which the professional component was performed.
  • The technical component should not be billed with the bilateral modifier -50. Payment is based on the lower of the submitted charge or the fee schedule for a single code. No additional payment is made when CPT code 76519-TC or 92136-TC is billed with the bilateral modifier 50.
  • If the technical portion of the procedure is only performed on one eye, the 52 modifier for reduced services should be used as well as the appropriate anatomic modifier (RT or LT).

Currently, the Medicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is “3” for the professional components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of “3” is as follows:

  • 3 = The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.

When the MPFSDB bilateral surgery indicator is “3,” the RVUs are calculated based on the procedure being performed as a unilateral procedure on each eye. Payment is based on the lower of the submitted charge or 100% of the fee schedule amount for each eye.

  • It is not uncommon for an IOL implant to be required for both eyes. When surgery for bilateral cataracts is scheduled several weeks apart, bill the professional component only when the IOL calculation is done within a timeframe that it can be used for the second planned surgery.
  • When the scan is performed and the calculation done on the first eye, bill the technical portion on one line (76519-TC or 92136-TC) and the professional component on a second line [76519 26-RT (or 26-LT) or 92136 26-RT (or 26-LT)].
    • Alternatively, bill the global code and use modifier RT or LT to indicate on which eye the professional component was performed [76519-RT (or LT) or 92136-RT (or LT)]. Do not submit modifier -50.
  • If the technical and professional components are performed on both eyes on the same date, bill the global service on one line and the second professional component on a second line, indicating the anatomic modifier (LT/RT) for the second eye.
  • One physician may do the technical component and another physician the professional component. Each will need to use the appropriate modifier, e.g., TC (technical component) or -26 (professional component). The professional component should also have the anatomic modifier (LT/RT) appended.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

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Scanning Computerized Ophthalmic Diagnostic Imaging LCD L34380

SCODI is a noninvasive, noncontact imaging technique. SCODI produces high resolution, cross-sectional tomographic images of ocular structures and is used for the evaluation of anterior segment and posterior segment disease.

Posterior segment SCODI allows for earlier detection of optic nerve and retinal nerve fiber layer pathologic changes before there is visual field loss. When appropriately used in the management of the glaucoma patient or glaucoma suspect, therapy can be initiated before there is irreversible loss of vision. This imaging technology provides the capability to discriminate among patients with normal intraocular pressures who have glaucoma, patients with elevated intraocular pressure who have glaucoma, and patients with elevated intraocular pressure who do not have glaucoma. SCODI also permits high resolution assessment of the retinal and choroidal layers, the presence of thickening associated with retinal edema, and of macular thickness measurement. Vitreo-retinal and vitreo-papillary relationships are displayed permitting surgical planning and assessment.

Anterior segment SCODI is used in the evaluation and treatment planning of diseases affecting the cornea, iris, and other anterior chamber structures. The procedure also may be used to provide additional information during the planning and follow-up for corneal, iris and cataract surgeries.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

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Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) L33567

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Fundus photography

Fundus photography involves the use of a retinal camera to document abnormalities of the retina and disease processes affecting the eye, in order to follow the progress of such disease. The test must be used in the medical decision making for the patient.

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Extended Ophthalmoscopy

Extended ophthalmoscopy is the detailed examination of the retina and always includes a true drawing of the retina, with interpretation and report. It is most frequently performed utilizing an indirect lens, although it may be performed using contact lens biomicroscopy. It may require scleral depression and is usually performed with the pupil dilated. It is performed by the physician when a more detailed examination (including that of the periphery) is needed, following routine ophthalmoscopy. The examination must be used in the medical decision making for the patient.

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Coding Guidelines

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

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Extended Ophthalmoscopy

CPT codes 92225 and 92226 are unilateral codes and must be submitted with a site modifier (LT, RT or 50). A claim without the appropriate modifier (RT, LT or 50) will be returned as incomplete. Each service must be billed with an NOS of 001, even if performed bilaterally and billed with a modifier 50.

An initial ophthalmoscopy (CPT code 92225) and a subsequent ophthalmoscopy (CPT code 92226) will not be reimbursed on the same day for the same eye by the same provider. If an initial ophthalmoscopy (CPT code 92225) and a subsequent ophthalmoscopy (CPT code 92226) are performed on different eyes modifier RT and LT should be reported to indicate that the services were performed on different eyes.

Extended ophthalmoscopy is classified as a professional service. The use of professional or technical component modifiers (26, TC), with these codes, is not appropriate.

CPT code 92225 is payable with ophthalmological examination codes 92002, 92004, 92012 and 92014. Code 92226 is payable only with exam codes 92012 and 92014.

If extended ophthalmoscopy is performed during a global surgery period, unrelated to the condition for which the surgery was performed (same provider), then the extended ophthalmoscopy should be coded with a modifier 79 attached (in addition to the appropriate site modifier).

The initial extended ophthalmoscopy code (92225) may be billed if the patient has had extended ophthalmoscopy (of the same eye) by the same physician/physician group within the last three (3) years.

Indirect ophthalmoscopy done without a drawing may not be billed separately and is part of a general ophthalmologic exam (92002‒92014).

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Fundus Photography

CPT codes 92250 and 92228 describe services that are performed bilaterally. Modifier 50 is never appropriate with these codes. Modifiers LT and RT should only be used if a unilateral service is performed.

CPT codes 92250 and 92228 are global services, which include a professional and a technical component. The components should be reported with modifiers 26 or TC as appropriate, if the entire global service is not performed.

CPT code 92227 (Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral) is considered screening and will be denied as non-covered. Claims for this service should be submitted with modifier GY.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

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Visual Fields Testing LCD L33574

Visual field testing detects defects in the field of vision, testing the function of the retina, optic nerve and optic pathways. Formal visual field tests are generally performed using automated perimetry, i.e., measurement of the ability to see points of light at varying locations on a curved surface.

Access the LCD for utilization guidelines, documentation guidelines and ICD-10 Codes that Support Medical Necessity.

Reviewed 10/13/2023