LCD Reference Article Billing and Coding Article

Billing and Coding: Implantable Miniature Telescope (IMT) for Macular Degeneration

A53501

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A53501
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Implantable Miniature Telescope (IMT) for Macular Degeneration
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

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Article Guidance

Article Text

The Implantable Miniature Telescope (IMT) is a prosthetic device in the form of a miniature telescope, implanted monocularly to enlarge the retinal image of the central visual field and reduce the impact of untreatable, severe-to-profound vision-impairing central scotomas associated with end stage age related macular degeneration (ARMD).

The implantable miniature telescope is considered medically reasonable and necessary only for patients who meet ALL of the following criteria:

• 65 years of age or older; and
• Diagnosis of stable, untreatable, severe-to-profound central vision impairment caused by blind spots (bilateral central scotoma) associated with end stage ARMD as determined by fluorescein angiography (findings of geographic atrophy or disciform scar with foveal involvement); and
• Evidence of a visually significant cataract (grade 2 or higher); and
• Corrected distance Snellen visual acuity poorer than 20/160 but no worse than 20/800; and
• No active wet ARMD (no sign of active choroidal neovascularization in either eye); and
• Have no sign of eye disease other than well controlled glaucoma; and
• Have not been treated for wet ARMD in the previous 6 months; and
• Achieve at least a 5 letter improvement on the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity chart in the eye scheduled for surgery using an external telescope; and
• Agree to undergo 2 to 4 pre-surgical training sessions with a low vision specialist (optometrist or occupational therapist); and
• Agree to participate in postoperative visual rehabilitation with a low vision specialist; and
• Complete and agree to the 'Acceptance of Risk and Informed Consent Agreement' provided in the device labeling documentation.

Note: Palmetto GBA expects performing providers to obtain adequate training prior to procedure performance. Medical records may be subject to review and/or denial if criteria are not documented and IMT contraindications are identified.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Do not report 0308T in conjunction with 65800 through 65815, 66020, 66030, 66600 through 66635, 66761, 66825, 66982 through 66986 or operating microscope code 69990.

Group 1 Codes
Code Description
0308T INSERTION OF OCULAR TELESCOPE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR INTRAOCULAR LENS PROSTHESIS
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(6 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
H35.3113 Nonexudative age-related macular degeneration, right eye, advanced atrophic without subfoveal involvement
H35.3114 Nonexudative age-related macular degeneration, right eye, advanced atrophic with subfoveal involvement
H35.3123 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement
H35.3124 Nonexudative age-related macular degeneration, left eye, advanced atrophic with subfoveal involvement
H35.3133 Nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement
H35.3134 Nonexudative age-related macular degeneration, bilateral, advanced atrophic with subfoveal involvement
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2020 R8

Under ICD-10 Codes that Support Medical Necessity – Group 1: Codes deleted codes H35.3110, H35.3111, H35.3112, H35.3120, H35.3121, H35.3122, H35.3130, H35.3131 and H35.3132.

10/03/2019 R7

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles.

02/26/2018 R6 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
10/01/2016 R5 Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes H35.3110, H35.3111, H35.3112, H35.3113, H35.3114, H35.3120, H35.3121, H35.3122, H35.3123, H35.3124, H35.3130, H35.3131, H35.3132, H35.3133, and H35.3134. Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 code H35.31. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2016.
04/21/2016 R4 Under Article Text the verbiage was revised for clarification. Under the bullet CPT Code 0308T added the full description of the service. The paragraph stating, “Do not report…” was moved under the CPT/HCPCS Codes section of the LCD. Under CPT/HCPCS Codes added verbiage to the paragraph “Do not report…” Under Statutory Requirements URL(s) deleted the cited url.
10/01/2015 R3 Under Covered ICD-10 Codes place H35.31 in this section of the article.
10/01/2015 R2 Under Article Text changed the qualifying age 75 to 65 years of age or older.
10/01/2015 R1 Added HCPCS codes from Article Text to the HCPCS Coding section.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/26/2020 10/01/2020 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Implantable
  • Miniature
  • Telescope
  • Macular Degeneration