Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27508

Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation

L27508

CPT codes, descriptions and other data only are copyright 2007 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.

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.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

There are two methods used for intraocular lens power calculation:

• A-Scan Ultrasound Ophthalmic Biometry
• Non-Ultrasound Ophthalmic Biometry

A-Scan is a biometric measurement of the axial length of the eye. An A-Scan converts the resulting echoes into waveforms whose crests represent the positions of different structures.

Optical Coherence Biometry (OCB) affords the measurement of ophthalmic biometry without ultrasound. The instrument utilized is a non-invasive, non-contact device, which measures the corneal curvature, anterior chamber depth and axial length of the eye without ultrasound. It uses interferometry or birefringent light instead of ultrasound to perform the biometry. All measurements are stored in a computer, as well as automatically transferred to the IOL calculator program, which allows the surgeon immediate and individualized computation of IOL implant options for the patient.

Indications

Ophthalmic biometry for IOL power calculation is indicated for patients who will undergo cataract extraction with lens implantation.

1. 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, including an A-scan.

2. 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 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.

Diagnostic Tests and X-Rays

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

When the only diagnosis is cataract(s), Medicare covers one comprehensive eye examination and an A-scan or OCB.  Optical Biometry for IOL calculation whether by A-scan of by OCB (codes 76519, 92136) is reasonable and necessary only in anticipation of cataract surgery with IOL implantation.  Therefore, it would be uncommon for patients to require this service more than once for the diagnosis of cataract(s).

Claim exceeding this frequency will be denied as medically not necessary unless the submitted documentation in the patient’s medical clearly supports the need for additional studies.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution: 04/01/2008

05/15/2008

05/23/2008

L27508

07/31/2008

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