Article - Billing and Coding: Corneal Pachymetry (A56548)

CMS National Coverage PolicyN/AArticle TextThis articlecontains codingand other guidelines that complement the Local Coverage Determination (LCD) for Corneal Pachymetry.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 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.CPT and Modifier CodingCPT 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.Documentation RequirementsMedical record documentation maintained by the ordering/referring physician must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in this policy, documentation of medical necessity must be submitted. This information is usually found in the history and physical, office/progress notes, or test results.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.Documentation should contain a history and physical which supports the diagnosis for which this service is being rendered.Utilization Guidelines:It is expected that these services 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.It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma or surgery.