Local Coverage Article

Eye Prostheses - Policy Article

A52462

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Contractor Information

Article Information

General Information

Article ID
A52462
Original ICD-9 Article ID
A33712
A47092
A33613
A33672
Article Title
Eye Prostheses - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
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 2020 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.

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Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

Eye prostheses are covered under the Medicare Artificial Legs, Arms and Eyes benefit (Social Security Act §1861(s)(9)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

Trial scleral cover shells are not separately payable. They are included in the allowance for scleral cover shells, V2627.

The following services and items are included in the allowance for a eye prosthesis and, therefore, are not separately billable to or payable by Medicare under the prosthetic device benefit:

  • Evaluation of the beneficiary

  • Pre-operative planning

  • Cost of materials

  • Labor involved in the fabrication and fitting of the prosthesis

  • Modifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafter

  • Repair due to normal wear or tear within 90 days of delivery

  • Follow-up visits within 90 days of delivery of the prosthesis

Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are required because of a change in the beneficiary’s condition.

Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess.

Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are noncovered services.

Claims for eye prostheses from nonphysicians provided in an office or nursing home setting are submitted to the DME MAC. Claims for eye prostheses from physicians in these settings are submitted to the applicable A/B MAC. Claims for eye prostheses provided in an outpatient hospital setting are submitted to the applicable A/B MAC. Eye prostheses provided in an inpatient hospital setting are included in the payment made to the hospital; therefore, claims should not be submitted to the DME MAC.

Claims for implanted components (e.g., titanium studs, magnets, etc) and procedures used to affix the ocular prosthesis to the beneficiary are not the jurisdiction of the DME MAC. Claims for these items and services will be denied as wrong jurisdiction.

Replacement of an ocular prosthesis because of loss or irreparable damage may be reimbursed without a treating practitioner's order when it is determined that the prosthesis as originally ordered still fills the beneficiary's medical needs.

 

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provides a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD- related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.

 

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.

When billing for an item or service at a greater frequency than that described in the policy, there must be documentation in the beneficiary’s medical records that corroborates the order and supports the medical necessity of the items and quantities billed. This information must be available upon request.

The treating practitioner's records must contain information which supports the medical necessity of the item ordered. The ocularist's documentation of the necessity for a replacement prosthesis is appropriate documentation for that claim if the replacement is necessitated by other than medical reasons.

 

CODING GUIDELINES

Trial scleral shells must be billed with code L9900.

The right (RT) and/or left (LT) modifiers must be used with all HCPCS codes in this policy. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without the RT and/or LT modifiers, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

PROSE Device 

PROSE (BostonSight, Needham, MA) devices are designed to rest on the sclera or white part of the eye and are used to treat ocular surfaces diseases, including some types of "dry eye." For Medicare billing purposes the correct HCPCS coding for this item is determined based upon the condition(s) being treated. When the PROSE device is used as a treatment for either of the following indications listed below, the correct HCPCS code to use is V2627 (SCLERAL COVER SHELL):

  • Treatment of an eye rendered sightless and shrunken by inflammatory disease; or,

  • Treatment of "dry eye" where the PROSE device serves as a substitute for the function of the diseased lacrimal gland.

When the PROSE device is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531 (CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)) and is subject to the Medicare refractive lens statutory coverage exclusion.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

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

N/A

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.

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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.

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2020 R7

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Removed: Trademark symbols from PROSE references, per AMA guidelines

03/25/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R6

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician’s” to “treating practitioner’s”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “physician’s” to “treating practitioner’s”
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

03/01/2019 R5

Revision Effective Date: 03/01/2019

CODING GUIDELINES:
Revised: RT and LT modifier billing instructions
Added: Coding guidelines for PROSE® device

02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R4

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: Information regarding implanted components

04/05/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

 

01/01/2017 R3 Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Reasonable Useful Lifetime verbiage
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: New reference language and directions to Standard Documentation Requirements
Added: Replacement instructions (previously in the related LCD)
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R2 Revision Effective Date: 07/01/2016
NON-MEDICAL NECESSITY COVERAGE & PAYMENT RULES:
Added: Instructions for services and items included in the allowance of the eye prostheses, and not separately billable
07/01/2016 R1 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Associated Documents

Related National Coverage Documents
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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
03/18/2021 01/01/2020 - N/A Currently in Effect You are here
02/14/2020 01/01/2020 - N/A Superseded View
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Keywords

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