Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

A47792

Article

No

Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation

A47792

Pennsylvania, Maryland, District of Columbia, DELAWARE

07/11/2008

08/01/2008

N/A

Coding Guidelines 

CPT codes 76519 (A-scan with IOL power calculation) and 92136 (Biometry by Partial Coherence Interferometry with IOL power calculation) have a bilateral technical component and a unilateral professional component. The professional component is normally done only for the eye for which surgery is planned.  Therefore, when either 76519 or 92136 is reported, the reimbursement includes payment for both eyes for the technical component and one eye for the professional component.  In this scenario, report 76519 or 92136 and indicate for which eye the professional component was performed (e.g., 76519 RT). 

Commonly, when a patient is diagnosed with bilateral cataracts, the surgeries are performed weeks apart.  In this instance, an IOL power calculation is necessary prior to the second surgery.  However, the technical portion of the test is not warranted again.  In this scenario it is necessary to indicate that only the professional component is being reported by appending the professional component "modifier 26" and identifying for which eye the calculation is being made, (e.g., 76519 LT-26 or 92136 RT-26). 

It is not appropriate for one physician/provider (physician "A") to bill for the global service, and then another physician/provider (physician "B") to bill for a re-read (professional component) of the same study. 

Cataract surgery should usually not be performed on both eyes on the same day, unless special circumstances exist (e.g., high risk for anesthesia, etc.).  In situations when these circumstances do exist, it would be necessary for the IOL power calculation to be performed bilaterally.  In this scenario it is necessary to indicate that the technical and professional components are being reported for both eyes (76519-26-50 and 76519-TC or 92136-26-50 and 92136-TC). 

Below are examples of appropriate coding for 76519 and 92136: 

• Test is performed on both eyes (TC) but calculation is performed on left eye only. Report: 76519-LT or 92136-LT 
• Test is performed on both eyes (TC) but calculation is performed on right eye only.  Report: 76519-RT or 92136-RT
• Test is performed on both eyes (TC) and calculation is performed on both eyes on the same day.  Report: 76519-TC and 76519-26-50 or 92136-TC and 92136-26-50 

Today, only the IOL power calculation is performed on the left eye (the IOL power calculation on the right eye and the technical component for both eyes was performed 3 weeks ago).  Report: 76519-LT-26 or 92136-LT-26 

Reasons for Denial

A-scans or OCB (76519 and 92136) with IOL calculation performed prior to cataract surgery reported in excess of the guidelines outlined in the LCD:  Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation 

Diagnostic ophthalmic echography and biometry performed in the absence of signs or symptoms is considered screening and is not a benefit of the Medicare program. 

Ophthalmic biometry provided for an indication not outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of LCD:  Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation. 

Any ICD-9 code reported that is not listed in the "ICD-9 Codes That Support Medical Necessity" section of LCD:  Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation will be denied. 

Diagnostic Tests and X-Rays

Other Comments

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.

A47792