Ophthalmic Biometry (L31624)
Contractor Information
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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
L31624 LCD Title Ophthalmic Biometry Contractor's Determination Number OPHTH-006 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 07/16/2011 Original Determination Ending Date Revision Effective Date Revision Ending Date |
CMS National Coverage Policy
CMS Pub.100-3 Ch.1 §10.1;
CMS Pub.100-4 Ch.23 §10-10.1.7
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
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) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.
CMS Pub.100-4 Ch.23 §10-10.1.7
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
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) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.
Indications and Limitations of Coverage and/or Medical Necessity
There are two methods used for intraocular lens power calculation:
1. A-Scan Ultrasound Biometry
2. Non-Ultrasound Ophthalmic Biometry
A-Scan Ophthalmic Ultrasound
A-Scan is a biometric measurement of the axial length of the eye to determine the power of an intraocular (IOL) lens implant. An A-Scan converts the resulting echos into waveforms whose crests represent the positions of different structures. The technical portion of ophthalmic biometry is usually performed in both eyes at the same setting.
Non-Ultrasound Ophthalmic Biometry
Optical coherence 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.
Indications
Ophthalmic biometry for IOL power calculation is indicated for patients who will undergo cataract extraction with lens implantation.
A. Ophthalmic biometry by ultrasound echography, A-scan
Ophthalmic A-scan is covered under Medicare when performed prior to cataract surgery. Because cataract surgery is an elective procedure, the patient may decide not to have surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be reasonable for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier's medical staff. (CMS Pub. 100-03, Ch. 1, §10.1.
B. Optical Coherence Biometry
Medicare will consider the performance of Optical Coherence Biometry (OCB) medically necessary if performed preoperatively by the operating surgeon or his/her designee for the purpose of determining intraocular lens power in a patient undergoing cataract surgery. Generally, it is expected that the provider who is performing the cataract surgery will perform OCB.
Limitations
CPT 76519 (A-scan with IOL power calculation) or OCB performed for reasons other than in preparation for anticipated cataract surgery with IOL implantation is not considered reasonable and necessary and will not be reimbursed.
It is not considered medically reasonable or necessary to perform both an A-scan (CPT code 76519) and an Optical Coherence Biometry (CPT code 92136). Whether on the same day or on different days, if both procedures are performed as part of one evaluation, only the A-scan (76519) will be paid.
Patients with poor fixating ability, significant ocular opacities, corneal ablations or dense posterior subcapsular cataracts along the visual axis may not be good candidates for OCB, and may require traditional A-Scan Ultrasound biometry with IOL power calculation (CPT 76519).
Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and the surgeon. If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If biometry is repeated by the operating surgeon due to the inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.
1. A-Scan Ultrasound Biometry
2. Non-Ultrasound Ophthalmic Biometry
A-Scan Ophthalmic Ultrasound
A-Scan is a biometric measurement of the axial length of the eye to determine the power of an intraocular (IOL) lens implant. An A-Scan converts the resulting echos into waveforms whose crests represent the positions of different structures. The technical portion of ophthalmic biometry is usually performed in both eyes at the same setting.
Non-Ultrasound Ophthalmic Biometry
Optical coherence 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.
Indications
Ophthalmic biometry for IOL power calculation is indicated for patients who will undergo cataract extraction with lens implantation.
A. Ophthalmic biometry by ultrasound echography, A-scan
Ophthalmic A-scan is covered under Medicare when performed prior to cataract surgery. Because cataract surgery is an elective procedure, the patient may decide not to have surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be reasonable for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier's medical staff. (CMS Pub. 100-03, Ch. 1, §10.1.
B. Optical Coherence Biometry
Medicare will consider the performance of Optical Coherence Biometry (OCB) medically necessary if performed preoperatively by the operating surgeon or his/her designee for the purpose of determining intraocular lens power in a patient undergoing cataract surgery. Generally, it is expected that the provider who is performing the cataract surgery will perform OCB.
Limitations
CPT 76519 (A-scan with IOL power calculation) or OCB performed for reasons other than in preparation for anticipated cataract surgery with IOL implantation is not considered reasonable and necessary and will not be reimbursed.
It is not considered medically reasonable or necessary to perform both an A-scan (CPT code 76519) and an Optical Coherence Biometry (CPT code 92136). Whether on the same day or on different days, if both procedures are performed as part of one evaluation, only the A-scan (76519) will be paid.
Patients with poor fixating ability, significant ocular opacities, corneal ablations or dense posterior subcapsular cataracts along the visual axis may not be good candidates for OCB, and may require traditional A-Scan Ultrasound biometry with IOL power calculation (CPT 76519).
Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and the surgeon. If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If biometry is repeated by the operating surgeon due to the inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.
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 |
| 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.
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.
| 032X | Radiology - Diagnostic - General Classification |
| 033X | Radiology - Therapeutic and/or Chemotherapy Administration - General Classification |
| 034X | Nuclear Medicine - General Classification |
| 035X | CT Scan - General Classification |
| 040X | Other Imaging Services - General Classification |
| 051X | Clinic - General Classification |
| 052X | Free-Standing Clinic - General Classification |
| 092X | Other Diagnostic Services - General Classification |
| 096X | Professional Fees - General Classification |
| 76516 | OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; |
| 76519 | OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR LENS POWER CALCULATION |
| 92136 | OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH INTRAOCULAR LENS POWER CALCULATION |
ICD-9 Codes that Support Medical Necessity
(For use with CPT codes 76516, 76519 and 92136)
| 366.00 - 366.46 | NONSENILE CATARACT UNSPECIFIED - CATARACT ASSOCIATED WITH RADIATION AND OTHER PHYSICAL INFLUENCES |
| 366.8 | OTHER CATARACT |
| 366.9 | UNSPECIFIED CATARACT |
| 379.31 - 379.34 | APHAKIA - POSTERIOR DISLOCATION OF LENS |
| 743.30 - 743.35 | CONGENITAL CATARACT UNSPECIFIED - CONGENITAL APHAKIA |
| 743.36 | CONGENITAL ANOMALIES OF LENS SHAPE |
| 743.37 | CONGENITAL ECTOPIC LENS |
| 743.39 | OTHER CONGENITAL CATARACT AND LENS ANOMALIES |
| 996.53 | MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS |
| 996.69 | INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT |
| V43.1 | LENS REPLACED BY OTHER MEANS |
Diagnoses that Support Medical Necessity
Diagnoses listed in the ICD-9 Codes that Support Medical Necessity section of this LCD
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the ICD-9 Codes that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Diagnoses that are not listed in the ICD-9 Codes that Support Medical Necessity section of this LCD
General Information
1. Physician
Services and diagnostic tests must be submitted with an ICD-9 code to
support medical necessity and must be coded to the greatest level of
accuracy and highest level of digit completeness. This means the
precise ICD-9 code that most fully explains the narrative description of
the diagnosis contained in the medical record or test interpretation
and report including the 4th or 5th digit subclassification for that
diagnosis category. The ICD-9 code based on the results of the
diagnostic test should be reported as 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 ICD-9 should
be reported and payment will be denied.
2. The patient's medical records should be legible, contain the relevant medical history and physical findings conforming to the criteria stated in the "Indication and Limitations of Coverage and/or Medical Necessity" section of this policy. Records must be made available to the Contractor on request.
Appendices
2. The patient's medical records should be legible, contain the relevant medical history and physical findings conforming to the criteria stated in the "Indication and Limitations of Coverage and/or Medical Necessity" section of this policy. Records must be made available to the Contractor on request.
1. Ophthalmic
biometry using A-scans (76519) and optical coherence biometry (92136)
for the same patient should not be billed by the same
provider/physician/group during a 12-month period. Claims for either of
these services in excess of these parameters will not be considered
medically necessary.
2. The technical portion of either 76519 or 92136 and the respective interpretations for the same patient should not be billed more than once during a 12 month period by the same provider/physician/group unless there is a significant change in vision. Claims in excess of these parameters will not be considered medically necessary.
*- An asterisk indicates a revision to that section of the policy.
Italicized font represents language quoted from Centers for Medicare and Medicaid Services (CMS)
Sources of Information and Basis for Decision
2. The technical portion of either 76519 or 92136 and the respective interpretations for the same patient should not be billed more than once during a 12 month period by the same provider/physician/group unless there is a significant change in vision. Claims in excess of these parameters will not be considered medically necessary.
*- An asterisk indicates a revision to that section of the policy.
Italicized font represents language quoted from Centers for Medicare and Medicaid Services (CMS)
CMS Pub.100-3 Ch.1 §10.1
Other Medicare Contractor Local Coverage Determinations
Advisory Committee Meeting Notes
Other Medicare Contractor Local Coverage Determinations
Wisconsin 01/28/2011
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
Iowa, Kansas, Missouri, Nebraska 02/10/2011
Open Meeting: 01/06/2011
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Start Date of Comment Period
Illinois 01/26/2011
Michigan 02/02/2011
Minnesota 01/20/2011
Iowa, Kansas, Missouri, Nebraska 02/10/2011
Open Meeting: 01/06/2011
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
02/10/2011
End Date of Comment Period
03/27/2011
Start Date of Notice Period
06/01/2011
Revision History Number
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).
05/16/2011 - Full replacement of all fields on policy for Draft being released to Final.
Reason for Change
05/16/2011 - Full replacement of all fields on policy for Draft being released to Final.
06/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
Billing & Coding Guidlines 6/1/11 (PDF - 25 KB )
Final Comments(a comment and response document) (PDF - 15 KB )
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Page Last Updated: Thursday, 21-Jul-2011 15:08:14 CDT
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