Computerized Corneal Topography (L31064)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L31064 LCD Title Computerized Corneal Topography Contractor's Determination Number OPHTH-014 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 12/16/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 07/01/2011 Revision Ending Date |
CMS National Coverage Policy
42CFR410.32
Diagnostic tests may only be ordered by the treating physician (or
other treating practitioners acting within the scope of their licenses
and Medicare requirements) who will use the results in the management of
the beneficiary's specific medical problem and diagnostic tests payable
under the Physicians Fee Schedule must be furnished under the
appropriate level of supervision by the physician.
CMS Pub.100-3 §80.7.1
CMS Pub.100-4 Ch.23 §§10-10.1.7
CMS Pub.100-3 §80.7.1
CMS Pub.100-4 Ch.23 §§10-10.1.7
Indications and Limitations of Coverage and/or Medical Necessity
Corneal
topography is a computer assisted diagnostic technique where a special
instrument projects a series of light rings on the cornea, creating a
color coded map of the corneal surface as well as a cross-section
profile. This service is used to provide a detailed map or chart of the
physical features and shape of the anterior surface of the cornea. This
permits a more accurate portrayal of the physical state of the cornea
and for the subtle detection of corneal surface irregularity and
astigmatism.
Computerized corneal topography is used to guide suture removal to reduce astigmatism following a penetrating keratoplasty (corneal transplant). Most sutures are removed between 3 to 24 months following surgery. By 2 years, all sutures that need to be removed have been, but the management of astigmatism following penetrating keratoplasty can extend beyond 2 years in the event of wound shifts, recurrent disease, or ulceration
Corneal Topography is indicated in the identification of deep or superficial corneal disorders/distortions causing irregular astigmatism and visual impairment. Results are used in assisting the physician in determining the appropriate surgical or medical treatment needed.
* Indications
Computerized corneal topography is considered medically necessary under any of the following conditions:
1. pre-operative evaluation of irregular astigmatism for intraocular lens power determination with cataract surgery;
2. monocular diplopia
3. diagnosis of early keratoconus;
4. post-surgical or post-traumatic astigmatism, measuring at a minimum of 3.5 diopters;
5. suspected irregular astigmatism based on retinoscopic streak or conventional keratometry;
6. post-penetrating keratoplasty surgery;
7. post-surgical or post-traumatic irregular astigmatism;
8. certain corneal dystrophies;
9. complications of transplanted cornea;
10. post-traumatic corneal scarring; and or
11. pterygium and or corneal ectasia that cause visual impairment.
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Computerized corneal topography is used to guide suture removal to reduce astigmatism following a penetrating keratoplasty (corneal transplant). Most sutures are removed between 3 to 24 months following surgery. By 2 years, all sutures that need to be removed have been, but the management of astigmatism following penetrating keratoplasty can extend beyond 2 years in the event of wound shifts, recurrent disease, or ulceration
Corneal Topography is indicated in the identification of deep or superficial corneal disorders/distortions causing irregular astigmatism and visual impairment. Results are used in assisting the physician in determining the appropriate surgical or medical treatment needed.
* Indications
Computerized corneal topography is considered medically necessary under any of the following conditions:
1. pre-operative evaluation of irregular astigmatism for intraocular lens power determination with cataract surgery;
2. monocular diplopia
3. diagnosis of early keratoconus;
4. post-surgical or post-traumatic astigmatism, measuring at a minimum of 3.5 diopters;
5. suspected irregular astigmatism based on retinoscopic streak or conventional keratometry;
6. post-penetrating keratoplasty surgery;
7. post-surgical or post-traumatic irregular astigmatism;
8. certain corneal dystrophies;
9. complications of transplanted cornea;
10. post-traumatic corneal scarring; and or
11. pterygium and or corneal ectasia that cause visual impairment.
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 071x | Clinic - Rural Health |
| 073x | Clinic - Freestanding |
| 077x | Clinic - Federally Qualified Health Center (FQHC) |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
| 0409 | Other Imaging Services - Other Imaging Services |
| 0510 | Clinic - General Classification |
| 0519 | Clinic - Other Clinic |
| 0520 | Free-Standing Clinic - General Classification |
| 0521 | Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC |
| 0523 | Free-Standing Clinic - Family Practice Clinic |
| 0529 | Free-Standing Clinic - Other Freestanding Clinic |
| 0920 | Other Diagnostic Services - General Classification |
| 0929 | Other Diagnostic Services - Other Diagnostic Service |
| 0960 | Professional Fees - General Classification |
| 0962 | Professional Fees - Ophthalmology |
| 92025 | COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT |
ICD-9 Codes that Support Medical Necessity
V43.1 and V45.61 must be accompanied by ICD-9 code 367.22
| 367.22 | IRREGULAR ASTIGMATISM |
| 368.2 | DIPLOPIA |
| 370.07 | MOOREN'S ULCER |
| 370.50 - 370.59 | INTERSTITIAL KERATITIS UNSPECIFIED - OTHER INTERSTITIAL AND DEEP KERATITIS |
| 370.8 | OTHER FORMS OF KERATITIS |
| 371.00 - 371.05 | CORNEAL OPACITY UNSPECIFIED - PHTHISICAL CORNEA |
| 371.20 | CORNEAL EDEMA UNSPECIFIED |
| 371.21 - 371.24 | IDIOPATHIC CORNEAL EDEMA - CORNEAL EDEMA DUE TO WEARING OF CONTACT LENSES |
| 371.40 | CORNEAL DEGENERATION UNSPECIFIED |
| 371.42 - 371.46 | RECURRENT EROSION OF CORNEA - NODULAR DEGENERATION OF CORNEA |
| 371.48 | PERIPHERAL DEGENERATIONS OF CORNEA |
| 371.49 | OTHER CORNEAL DEGENERATIONS |
| 371.50 - 371.58 | HEREDITARY CORNEAL DYSTROPHY UNSPECIFIED - OTHER POSTERIOR CORNEAL DYSTROPHIES |
| 371.60 - 371.62 | KERATOCONUS UNSPECIFIED - KERATOCONUS ACUTE HYDROPS |
| 371.70 - 371.73 | CORNEAL DEFORMITY UNSPECIFIED - CORNEAL STAPHYLOMA |
| 372.40 - 372.45 | PTERYGIUM UNSPECIFIED - RECURRENT PTERYGIUM |
| 372.52 | PSEUDOPTERYGIUM |
| 743.22 | BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES |
| 743.41 | CONGENITAL ANOMALIES OF CORNEAL SIZE AND SHAPE |
| 871.0 | OCULAR LACERATION WITHOUT PROLAPSE OF INTRAOCULAR TISSUE |
| 871.1 | OCULAR LACERATION WITH PROLAPSE OR EXPOSURE OF INTRAOCULAR TISSUE |
| 871.5 | PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY |
| 871.6 | PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY |
| 940.0 | CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA |
| 940.2 - 940.4 | ALKALINE CHEMICAL BURN OF CORNEA AND CONJUNCTIVAL SAC - OTHER BURN OF CORNEA AND CONJUNCTIVAL SAC |
| 996.51 | MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT |
| 996.53 | MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS |
| 998.83 | NON-HEALING SURGICAL WOUND |
| V42.5 | CORNEA REPLACED BY TRANSPLANT |
| V43.1 | LENS REPLACED BY OTHER MEANS |
| V45.61 | CATARACT EXTRACTION STATUS |
| V45.69 | OTHER STATES FOLLOWING SURGERY OF EYE AND ADNEXA |
Diagnoses that Support Medical Necessity
Any listed above
ICD-9 Codes that DO NOT Support Medical Necessity
Any NOT listed above
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Any NOT Listed above
General Information
1. The patient's
medical records should be legible and contain the relevant history and
physical findings conforming to the criteria stated in the "Indication
and Limitations of Coverage and/or Medical Necessity" section above and
must be made available to the Carrier on request. The patient's record
should also include the computerized corneal topography results with
examination and photo interpretation.
2. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening diagnosis should be reported, and payment will be denied.
3. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
4. For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Appendices
2. Physicians' Services and diagnostic tests must be submitted with an ICD-9 code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the 4th or 5th digit sub-classification for the diagnosis category. The ICD-9 code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening diagnosis should be reported, and payment will be denied.
3. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
4. For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
*It is expected that
computerized corneal topography would be performed as indicated by
current medical literature and/or standards of practice. When services
are performed in excess of established parameters, they may be subject
to review for medical necessity.
*Repeat testing is only indicated if a change in vision occurs with one of the conditions listed under the Indications section of this LCD.
*Corneal topography should not be reported with or during the post-operative period for corneal procedures, e.g., 65710, 65730, 65750, 65755, 65756, 65757, and 65770.
Sources of Information and Basis for Decision
*Repeat testing is only indicated if a change in vision occurs with one of the conditions listed under the Indications section of this LCD.
*Corneal topography should not be reported with or during the post-operative period for corneal procedures, e.g., 65710, 65730, 65750, 65755, 65756, 65757, and 65770.
Canadian Journal of Ophthalmology, 1992, August 27 (5) pp. 213-225
CMD Ophthalmology Clinical Work Group; American Association of Ophthalmology (AAO)
Corneal Topography Ophthalmic Procedure Preliminary Assessment; Ophthalmology 1999; 106i162B-1638
Journal of Cataract and Refractory Surgery, 1993, Vol. 19, Suppl pp.131-135
Survey of Ophthalmology, 1991, January/February issue, Vol. 35 (4), pp. 269-277
Advisory Committee Meeting Notes
CMD Ophthalmology Clinical Work Group; American Association of Ophthalmology (AAO)
Corneal Topography Ophthalmic Procedure Preliminary Assessment; Ophthalmology 1999; 106i162B-1638
Journal of Cataract and Refractory Surgery, 1993, Vol. 19, Suppl pp.131-135
Survey of Ophthalmology, 1991, January/February issue, Vol. 35 (4), pp. 269-277
Meeting Date:
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
Iowa, Kansas, Missouri, Nebraska 06/24/2010
Date of the Open Meeting: 04/22/2010
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from Ophthalmology, and Optometry.
Italicized font - represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Carriers are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
Start Date of Comment Period
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
Iowa, Kansas, Missouri, Nebraska 06/24/2010
Date of the Open Meeting: 04/22/2010
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from Ophthalmology, and Optometry.
Italicized font - represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Carriers are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
06/24/2010
End Date of Comment Period
08/08/2010
Start Date of Notice Period
11/01/2010
Revision History Number
1
Revision History Explanation
02/21/2011 - In
accordance with Section 911 of the Medicare Modernization Act of 2003,
the states of Delaware, District of Columbia, Maryland, New Jersey and
Pennsylvania were removed from this LCD because claims processing for
these states are transitioning from FI Wisconsin Physician Service (WPS
52280) to MAC Part A contractor Highmark (12901).
07/01/2011: Clarified LCD to state that corneal topography should not be reported with or during the post-operative period for corneal procedures, e.g., 65710, 65730, 65750, 65755, 65756, 65757, and 65770. Removed statements 1, 2, 3, 4, and 5 listed in the section entitled Indications and Limitations of Coverage and/or Medical Necessity. For the purpose of clarity, added a section entitled Indications.
Clarified and added instructions to Utilization Guidelines section. Coding instructions for CPT codes 65710, 65730, 65750, 65755, 65756, 65757 and 65770 effective from DOS 12/16/2010 and thereafter (one).
Reason for Change
07/01/2011: Clarified LCD to state that corneal topography should not be reported with or during the post-operative period for corneal procedures, e.g., 65710, 65730, 65750, 65755, 65756, 65757, and 65770. Removed statements 1, 2, 3, 4, and 5 listed in the section entitled Indications and Limitations of Coverage and/or Medical Necessity. For the purpose of clarity, added a section entitled Indications.
Clarified and added instructions to Utilization Guidelines section. Coding instructions for CPT codes 65710, 65730, 65750, 65755, 65756, 65757 and 65770 effective from DOS 12/16/2010 and thereafter (one).
06/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
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Page Last Updated: Wednesday, 05-Oct-2011 15:14:33 CDT
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