LCD Reference Article Billing and Coding Article

Billing and Coding: Corneal Pachymetry

A56457

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	MAC - Part A	15101 - MAC A	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part B	15102 - MAC B	J - 15	Kentucky
CGS Administrators, LLC	MAC - Part A	15201 - MAC A	J - 15	Ohio
CGS Administrators, LLC	MAC - Part B	15202 - MAC B	J - 15	Ohio

Article Information

General Information

Article ID
A56457

Article Title
Billing and Coding: Corneal Pachymetry

Article Type
Billing and Coding

Original Effective Date
10/01/2016

Revision Effective Date
02/01/2024

Revision Ending Date
N/A

Retirement Date
N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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.

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

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33999-Corneal Pachymetry.

General Guidelines for Claims submitted to Part A or Part B MAC:

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.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
Relevant medical history
Results of pertinent tests/procedures
Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Response To Comments

Number	Comment	Response
1

Coding Information

Bill Type Codes

Code	Description
012x	Hospital Inpatient (Medicare Part B only)
013x	Hospital Outpatient
018x	Hospital - Swing Beds
021x	Skilled Nursing - Inpatient (Including Medicare Part A)
022x	Skilled Nursing - Inpatient (Medicare Part B only)
023x	Skilled Nursing - Outpatient
071x	Clinic - Rural Health
073x	Clinic - Freestanding
077x	Clinic - Federally Qualified Health Center (FQHC)
085x	Critical Access Hospital

Revenue Codes

Code	Description
0402	Other Imaging Services - Ultrasound
0972	Professional Fees - Radiology - Diagnostic

CPT/HCPCS Codes

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Group 1

(1 Code)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
76514	OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS)

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(214 Codes)

Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Group 1 Codes

Code	Description
H18.11 - H18.13	Bullous keratopathy, right eye - Bullous keratopathy, bilateral
H18.461 - H18.463	Peripheral corneal degeneration, right eye - Peripheral corneal degeneration, bilateral
H18.511	Endothelial corneal dystrophy, right eye
H18.512	Endothelial corneal dystrophy, left eye
H18.513	Endothelial corneal dystrophy, bilateral
H18.591	Other hereditary corneal dystrophies, right eye
H18.592	Other hereditary corneal dystrophies, left eye
H18.593	Other hereditary corneal dystrophies, bilateral
H18.601 - H18.603	Keratoconus, unspecified, right eye - Keratoconus, unspecified, bilateral
H18.611 - H18.613	Keratoconus, stable, right eye - Keratoconus, stable, bilateral
H18.621 - H18.623	Keratoconus, unstable, right eye - Keratoconus, unstable, bilateral
H21.551 - H21.553	Recession of chamber angle, right eye - Recession of chamber angle, bilateral
H40.001 - H40.003	Preglaucoma, unspecified, right eye - Preglaucoma, unspecified, bilateral
H40.011 - H40.013	Open angle with borderline findings, low risk, right eye - Open angle with borderline findings, low risk, bilateral
H40.021 - H40.023	Open angle with borderline findings, high risk, right eye - Open angle with borderline findings, high risk, bilateral
H40.031 - H40.033	Anatomical narrow angle, right eye - Anatomical narrow angle, bilateral
H40.041 - H40.043	Steroid responder, right eye - Steroid responder, bilateral
H40.051 - H40.053	Ocular hypertension, right eye - Ocular hypertension, bilateral
H40.061 - H40.063	Primary angle closure without glaucoma damage, right eye - Primary angle closure without glaucoma damage, bilateral
H40.10X1	Unspecified open-angle glaucoma, mild stage
H40.10X2	Unspecified open-angle glaucoma, moderate stage
H40.10X3	Unspecified open-angle glaucoma, severe stage
H40.10X4	Unspecified open-angle glaucoma, indeterminate stage
H40.1111	Primary open-angle glaucoma, right eye, mild stage
H40.1112	Primary open-angle glaucoma, right eye, moderate stage
H40.1113	Primary open-angle glaucoma, right eye, severe stage
H40.1114	Primary open-angle glaucoma, right eye, indeterminate stage
H40.1121	Primary open-angle glaucoma, left eye, mild stage
H40.1122	Primary open-angle glaucoma, left eye, moderate stage
H40.1123	Primary open-angle glaucoma, left eye, severe stage
H40.1124	Primary open-angle glaucoma, left eye, indeterminate stage
H40.1131	Primary open-angle glaucoma, bilateral, mild stage
H40.1132	Primary open-angle glaucoma, bilateral, moderate stage
H40.1133	Primary open-angle glaucoma, bilateral, severe stage
H40.1134	Primary open-angle glaucoma, bilateral, indeterminate stage
H40.1210 - H40.1214	Low-tension glaucoma, right eye, stage unspecified - Low-tension glaucoma, right eye, indeterminate stage
H40.1220 - H40.1224	Low-tension glaucoma, left eye, stage unspecified - Low-tension glaucoma, left eye, indeterminate stage
H40.1230 - H40.1234	Low-tension glaucoma, bilateral, stage unspecified - Low-tension glaucoma, bilateral, indeterminate stage
H40.1290	Low-tension glaucoma, unspecified eye, stage unspecified
H40.1310 - H40.1314	Pigmentary glaucoma, right eye, stage unspecified - Pigmentary glaucoma, right eye, indeterminate stage
H40.1320 - H40.1324	Pigmentary glaucoma, left eye, stage unspecified - Pigmentary glaucoma, left eye, indeterminate stage
H40.1330 - H40.1334	Pigmentary glaucoma, bilateral, stage unspecified - Pigmentary glaucoma, bilateral, indeterminate stage
H40.1410 - H40.1414	Capsular glaucoma with pseudoexfoliation of lens, right eye, stage unspecified - Capsular glaucoma with pseudoexfoliation of lens, right eye, indeterminate stage
H40.1420 - H40.1424	Capsular glaucoma with pseudoexfoliation of lens, left eye, stage unspecified - Capsular glaucoma with pseudoexfoliation of lens, left eye, indeterminate stage
H40.1430 - H40.1434	Capsular glaucoma with pseudoexfoliation of lens, bilateral, stage unspecified - Capsular glaucoma with pseudoexfoliation of lens, bilateral, indeterminate stage
H40.151 - H40.153	Residual stage of open-angle glaucoma, right eye - Residual stage of open-angle glaucoma, bilateral
H40.20X1	Unspecified primary angle-closure glaucoma, mild stage
H40.20X2	Unspecified primary angle-closure glaucoma, moderate stage
H40.20X3	Unspecified primary angle-closure glaucoma, severe stage
H40.20X4	Unspecified primary angle-closure glaucoma, indeterminate stage
H40.211 - H40.213	Acute angle-closure glaucoma, right eye - Acute angle-closure glaucoma, bilateral
H40.2210 - H40.2214	Chronic angle-closure glaucoma, right eye, stage unspecified - Chronic angle-closure glaucoma, right eye, indeterminate stage
H40.2220 - H40.2224	Chronic angle-closure glaucoma, left eye, stage unspecified - Chronic angle-closure glaucoma, left eye, indeterminate stage
H40.2231 - H40.2234	Chronic angle-closure glaucoma, bilateral, mild stage - Chronic angle-closure glaucoma, bilateral, indeterminate stage
H40.2291 - H40.2294	Chronic angle-closure glaucoma, unspecified eye, mild stage - Chronic angle-closure glaucoma, unspecified eye, indeterminate stage
H40.231 - H40.233	Intermittent angle-closure glaucoma, right eye - Intermittent angle-closure glaucoma, bilateral
H40.241 - H40.243	Residual stage of angle-closure glaucoma, right eye - Residual stage of angle-closure glaucoma, bilateral
H40.31X1	Glaucoma secondary to eye trauma, right eye, mild stage
H40.31X2	Glaucoma secondary to eye trauma, right eye, moderate stage
H40.31X3	Glaucoma secondary to eye trauma, right eye, severe stage
H40.31X4	Glaucoma secondary to eye trauma, right eye, indeterminate stage
H40.32X1	Glaucoma secondary to eye trauma, left eye, mild stage
H40.32X2	Glaucoma secondary to eye trauma, left eye, moderate stage
H40.32X3	Glaucoma secondary to eye trauma, left eye, severe stage
H40.32X4	Glaucoma secondary to eye trauma, left eye, indeterminate stage
H40.33X1	Glaucoma secondary to eye trauma, bilateral, mild stage
H40.33X2	Glaucoma secondary to eye trauma, bilateral, moderate stage
H40.33X3	Glaucoma secondary to eye trauma, bilateral, severe stage
H40.33X4	Glaucoma secondary to eye trauma, bilateral, indeterminate stage
H40.41X1	Glaucoma secondary to eye inflammation, right eye, mild stage
H40.41X2	Glaucoma secondary to eye inflammation, right eye, moderate stage
H40.41X3	Glaucoma secondary to eye inflammation, right eye, severe stage
H40.41X4	Glaucoma secondary to eye inflammation, right eye, indeterminate stage
H40.42X1	Glaucoma secondary to eye inflammation, left eye, mild stage
H40.42X2	Glaucoma secondary to eye inflammation, left eye, moderate stage
H40.42X3	Glaucoma secondary to eye inflammation, left eye, severe stage
H40.42X4	Glaucoma secondary to eye inflammation, left eye, indeterminate stage
H40.43X1	Glaucoma secondary to eye inflammation, bilateral, mild stage
H40.43X2	Glaucoma secondary to eye inflammation, bilateral, moderate stage
H40.43X3	Glaucoma secondary to eye inflammation, bilateral, severe stage
H40.43X4	Glaucoma secondary to eye inflammation, bilateral, indeterminate stage
H40.51X1	Glaucoma secondary to other eye disorders, right eye, mild stage
H40.51X2	Glaucoma secondary to other eye disorders, right eye, moderate stage
H40.51X3	Glaucoma secondary to other eye disorders, right eye, severe stage
H40.51X4	Glaucoma secondary to other eye disorders, right eye, indeterminate stage
H40.52X1	Glaucoma secondary to other eye disorders, left eye, mild stage
H40.52X2	Glaucoma secondary to other eye disorders, left eye, moderate stage
H40.52X3	Glaucoma secondary to other eye disorders, left eye, severe stage
H40.52X4	Glaucoma secondary to other eye disorders, left eye, indeterminate stage
H40.53X1	Glaucoma secondary to other eye disorders, bilateral, mild stage
H40.53X2	Glaucoma secondary to other eye disorders, bilateral, moderate stage
H40.53X3	Glaucoma secondary to other eye disorders, bilateral, severe stage
H40.53X4	Glaucoma secondary to other eye disorders, bilateral, indeterminate stage
H40.60X1	Glaucoma secondary to drugs, unspecified eye, mild stage
H40.60X2	Glaucoma secondary to drugs, unspecified eye, moderate stage
H40.60X3	Glaucoma secondary to drugs, unspecified eye, severe stage
H40.60X4	Glaucoma secondary to drugs, unspecified eye, indeterminate stage
H40.61X1	Glaucoma secondary to drugs, right eye, mild stage
H40.61X2	Glaucoma secondary to drugs, right eye, moderate stage
H40.61X3	Glaucoma secondary to drugs, right eye, severe stage
H40.61X4	Glaucoma secondary to drugs, right eye, indeterminate stage
H40.62X1	Glaucoma secondary to drugs, left eye, mild stage
H40.62X2	Glaucoma secondary to drugs, left eye, moderate stage
H40.62X3	Glaucoma secondary to drugs, left eye, severe stage
H40.62X4	Glaucoma secondary to drugs, left eye, indeterminate stage
H40.63X1	Glaucoma secondary to drugs, bilateral, mild stage
H40.63X2	Glaucoma secondary to drugs, bilateral, moderate stage
H40.63X3	Glaucoma secondary to drugs, bilateral, severe stage
H40.63X4	Glaucoma secondary to drugs, bilateral, indeterminate stage
H40.811 - H40.813	Glaucoma with increased episcleral venous pressure, right eye - Glaucoma with increased episcleral venous pressure, bilateral
H40.821 - H40.823	Hypersecretion glaucoma, right eye - Hypersecretion glaucoma, bilateral
H40.831 - H40.833	Aqueous misdirection, right eye - Aqueous misdirection, bilateral
H40.89	Other specified glaucoma
H40.9	Unspecified glaucoma
H42	Glaucoma in diseases classified elsewhere
Q15.0	Congenital glaucoma
T85.318A	Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter
T85.328A	Displacement of other ocular prosthetic devices, implants and grafts, initial encounter
T86.8401	Corneal transplant rejection, right eye
T86.8402	Corneal transplant rejection, left eye
T86.8403	Corneal transplant rejection, bilateral
T86.8411	Corneal transplant failure, right eye
T86.8412	Corneal transplant failure, left eye
T86.8413	Corneal transplant failure, bilateral

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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
012x	Hospital Inpatient (Medicare Part B only)
013x	Hospital Outpatient
018x	Hospital - Swing Beds
021x	Skilled Nursing - Inpatient (Including Medicare Part A)
022x	Skilled Nursing - Inpatient (Medicare Part B only)
023x	Skilled Nursing - Outpatient
071x	Clinic - Rural Health
073x	Clinic - Freestanding
077x	Clinic - Federally Qualified Health Center (FQHC)
085x	Critical Access Hospital

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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

Code	Description
0402	Other Imaging Services - Ultrasound
0972	Professional Fees - Radiology - Diagnostic

Other Coding Information

N/A

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
			N/A	N/A

Non-Excluded CPT/HCPCS Ended Codes - Table Format

Code	Descriptor Generic Name	Descriptor Brand Name	Exclusion Effective Date	Exclusion End Date	Reason for Exclusion

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
02/01/2024	R8	Revision Effective: 02/01/2024 Revision Explanation: Annual review, no changes made.
11/16/2023	R7	Revision Effective: 11/16/2023 Revision Explanation: Updated LCD Reference Article section.
01/26/2023	R6	Revision Effective: 01/26/2023 Revision Explanation: Annual Review, no changes were made.
02/03/2022	R5	Revision Effective: 02/03/2022 Revision Explanation: Annual Review, no changes were made
01/28/2021	R4	Revision Effective: 01/28/2021 Revision Explanation: Annual Review, no changes were made
09/19/2019	R3	R3 Revision Effective: 10/01/2020 Revision Explanation: During the annual ICD-10 annual review H18.51, H18.59, T86.840 and T86.841 were deleted and replaced with the following codes: H18.511, H18.512, H18.513, H18.591, H18.592, H18.593, T86.8401, T86.8402, T86.8403, T86.8411, T86.8412, and T86.8413. Also removed duplicate wording of Billing and Coding in the title.
09/19/2019	R2	Revision Effective: N/A Revision Explanation: Annual Review, no changes
09/19/2019	R1	R1 Revision Effective: 09/19/2019 Revision Explanation: Converted article into new Billing and Coding template no other changes made.

Associated Documents

Related Local Coverage Documents
LCDs
L33999 - Corneal Pachymetry

Updated On	Effective Dates	Status
01/25/2024	02/01/2024 - N/A	Currently in Effect	You are here
11/08/2023	11/16/2023 - 01/31/2024	Superseded	View
01/20/2023	01/26/2023 - 11/15/2023	Superseded	View
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Billing and Coding: Corneal Pachymetry

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