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Issue Number - Name
0159-Ophthalmic Diagnostic CPT Codes:Excessive Units
Review Type
Automated
Provider Type
Professional Services
MAC Jurisdiction
All A/B MACs
Date Approved
06/04/2019

Description

Based on CPT Code descriptions, CPT Code 92133 and 92134 cannot be reported at the same patient encounter.  Only one is allowed per day, therefore the lower allowed amount CPT Code will be recovered as an overpayment.

Affected Codes

92133, 92134

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980 - Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §405.986 - Good Cause for Reopening
5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
6. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 – current (Special Ophthalmological Services)