Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A56549)

CMS National Coverage PolicyN/AArticle TextThis article containscoding and other guidelines that complement the Local Coverage Determination (LCD) for Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation.Coding Information: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 diagnoses 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.Specific coding guidelines:Currently, theMedicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is 2 for the global and technical componentsof 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 CPT code 76519-TC or 92136 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, theMedicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is 3 for the professional componentsof 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 thefirsteye, 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 onboth 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.National Coverage Requirements:Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used.For patients with a dense cataract, an ultrasound B-scan may be used. (CMS Publication 100-03,Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1)Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented.(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 10.1)Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carriers medical staff, they are covered.(CMS Publication 100-03,Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1)Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. This documentation should include at a minimum the patients name and date of service, the indications for testing, an order for testing, the results of testing, and the IOL power calculation. Documentation must be available to Medicare upon request.Utilization Guidelines: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 be considered not 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 be considered not medically necessary.