Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy L34181-Ophthalmic Biometry for Intraocular
Lens Power Calculation.

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.  
  
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.

**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.



**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

**For claims submitted to the Part B MAC:**  
  
All services/procedures performed on the same day for the same beneficiary by
the physician/provider should be billed on the same claim.  
  
Claims for intraocular lens power calculation services are payable under
Medicare Part B in the following places of service:

  * The global is payable in the office (11) and independent clinic (49) for CPT codes 76519 and 92136.
  * The technical component is payable in the office (11); independent clinic (49); federally qualified health center (50); and rural health clinic (72) for CPT codes 76519 and 92136.
  * The professional components are payable in the office (11), off campus-outpatient hospital (19), inpatient hospital (21), on campus-outpatient hospital (22), ambulatory surgical center (24) and independent clinic (49) for 76519 and payable in the office (11), off campus-outpatient hospital (19), inpatient hospital (21), on campus-outpatient hospital (22), and independent clinic (49) for 92136.

The National Correct Coding Initiative (NCCI) may include edits for these CPT
codes. Currently, NCCI edits for CPT codes 76519 and 92136 are as follows:

  * Procedure code 76519 includes services performed for procedure 76516. Separate reimbursement will not be made for 76516 when billed with 76519;
  * Payment for 76519 and 92136 for the same patient, same provider, same day will not be made.



Currently, the **Medicare Physician Fee Schedule Database (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 relative value units
(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 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.

**Effective January 1, 2017 the professional component for 76519 and 92136 was
changed to a bilateral indicator of 2 and will follow the same rules as
outlined above for the global and technical component of these codes.**

**For claims submitted to the Part A MAC:**  
  
 _Hospital Inpatient Claims:_

  * The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. _The principal diagnosis is the condition established after study to be chiefly responsible for this admission.  
_

  * _The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67._
  * For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, _Medicare Claims Processing Manual_ , Chapter 25, Section 75 for additional instructions.)
  * For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.

_Hospital Outpatient Claims:_

  * _The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient 's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).  
_

  * _The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67._

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.

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.