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LCD Reference Article Billing and Coding Article

Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation

A56549

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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.

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Source Article ID
N/A
Article ID
A56549
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation
Article Type
Billing and Coding
Original Effective Date
08/01/2019
Revision Effective Date
09/19/2019
Revision Ending Date
N/A
Retirement Date
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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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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation. 

Coding Information:

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 diagnoses 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.

Specific coding guidelines:

Currently, the Medicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is “2” for the global and technical components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of “2” is as follows:

  • 2 = 150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.

When the MPFSDB bilateral surgery indicator is “2”, the relative value units (RVUs) are based on the procedure performed on each eye.

  • The global service includes the bilateral technical component (76519-TC or 92136-TC) and a unilateral professional service (76519-26 or 92136-26). The anatomic modifier (-RT or -LT) should be used to indicate the eye on which the professional component was performed.
  • The technical component should not be billed with the bilateral modifier -50. Payment is based on the lower of the submitted charge or the fee schedule for a single code. No additional payment is made when CPT code 76519-TC or 92136 is billed with the bilateral modifier -50.
  • If the technical portion of the procedure is only performed on one eye, the -52 modifier for reduced services should be used as well as the appropriate anatomic modifier (-RT or -LT).

Currently, the Medicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is “3” for the professional components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of “3” is as follows:

  • 3= The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.

When the MPFSDB bilateral surgery indicator is “3”, the RVUs are calculated based on the procedure being performed as a unilateral procedure on each eye. Payment is based on the lower of the submitted charge or 100% of the fee schedule amount for each eye.

  • It is not uncommon for an IOL implant to be required for both eyes. When surgery for bilateral cataracts is scheduled several weeks apart, bill the professional component only when the IOL calculation is done within a timeframe that it can be used for the second planned surgery.
  • When the scan is performed and the calculation done on the first eye, bill the technical portion on one line (76519-TC or 92136-TC) and the professional component on a second line [76519 26-RT (or 26-LT) or 92136 26-RT (or 26-LT)].
    • Alternatively, bill the global code and use modifier -RT or -LT to indicate on which eye the professional component was performed [76519-RT (or -LT) or 92136-RT (or –LT)]. Do not submit modifier -50.
  • If the technical and professional components are performed on both eyes on the same date, bill the global service on one line and the second professional component on a second line, indicating the anatomic modifier (-LT/-RT) for the second eye.
  • One physician may do the technical component and another physician the professional component. Each will need to use the appropriate modifier, e.g., -TC (technical component) or -26 (professional component). The professional component should also have the anatomic modifier (-LT/-RT) appended.

National Coverage Requirements:

Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used. (CMS Publication 100-03, Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1‎)

Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 10.1‎)

Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier’s medical staff, they are covered. (CMS Publication 100-03, Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1‎)

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. This documentation should include at a minimum the patient’s name and date of service, the indications for testing, an order for testing, the results of testing, and the IOL power calculation. Documentation must be available to Medicare upon request.

Utilization Guidelines:

Ophthalmic biometry using A-scans (76519) and optical coherence biometry (92136) for the same patient should not be billed by the same provider/physician/group during a 12-month period. Claims for either of these services in excess of these parameters will be considered not medically necessary.

The technical portion of either 76519 or 92136 and the respective interpretations for the same patient should not be billed more than once during a 12 month period by the same provider/physician/group unless there is a significant change in vision. Claims in excess of these parameters will be considered not medically necessary.

Response To Comments

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Coding Information

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CPT/HCPCS Codes

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Code Description
76519 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR LENS POWER CALCULATION
92136 OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH INTRAOCULAR LENS POWER CALCULATION
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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(97 Codes)
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The 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 the attached determination.

 Group 1 Codes
Code Description
E10.36 Type 1 diabetes mellitus with diabetic cataract
E11.36 Type 2 diabetes mellitus with diabetic cataract
E13.36 Other specified diabetes mellitus with diabetic cataract
H25.011 Cortical age-related cataract, right eye
H25.012 Cortical age-related cataract, left eye
H25.013 Cortical age-related cataract, bilateral
H25.031 Anterior subcapsular polar age-related cataract, right eye
H25.032 Anterior subcapsular polar age-related cataract, left eye
H25.033 Anterior subcapsular polar age-related cataract, bilateral
H25.041 Posterior subcapsular polar age-related cataract, right eye
H25.042 Posterior subcapsular polar age-related cataract, left eye
H25.043 Posterior subcapsular polar age-related cataract, bilateral
H25.11 Age-related nuclear cataract, right eye
H25.12 Age-related nuclear cataract, left eye
H25.13 Age-related nuclear cataract, bilateral
H25.21 Age-related cataract, morgagnian type, right eye
H25.22 Age-related cataract, morgagnian type, left eye
H25.23 Age-related cataract, morgagnian type, bilateral
H25.811 Combined forms of age-related cataract, right eye
H25.812 Combined forms of age-related cataract, left eye
H25.813 Combined forms of age-related cataract, bilateral
H25.89 Other age-related cataract
H25.9 Unspecified age-related cataract
H26.001 Unspecified infantile and juvenile cataract, right eye
H26.002 Unspecified infantile and juvenile cataract, left eye
H26.003 Unspecified infantile and juvenile cataract, bilateral
H26.011 Infantile and juvenile cortical, lamellar, or zonular cataract, right eye
H26.012 Infantile and juvenile cortical, lamellar, or zonular cataract, left eye
H26.013 Infantile and juvenile cortical, lamellar, or zonular cataract, bilateral
H26.031 Infantile and juvenile nuclear cataract, right eye
H26.032 Infantile and juvenile nuclear cataract, left eye
H26.033 Infantile and juvenile nuclear cataract, bilateral
H26.041 Anterior subcapsular polar infantile and juvenile cataract, right eye
H26.042 Anterior subcapsular polar infantile and juvenile cataract, left eye
H26.043 Anterior subcapsular polar infantile and juvenile cataract, bilateral
H26.051 Posterior subcapsular polar infantile and juvenile cataract, right eye
H26.052 Posterior subcapsular polar infantile and juvenile cataract, left eye
H26.053 Posterior subcapsular polar infantile and juvenile cataract, bilateral
H26.061 Combined forms of infantile and juvenile cataract, right eye
H26.062 Combined forms of infantile and juvenile cataract, left eye
H26.063 Combined forms of infantile and juvenile cataract, bilateral
H26.09 Other infantile and juvenile cataract
H26.101 Unspecified traumatic cataract, right eye
H26.102 Unspecified traumatic cataract, left eye
H26.103 Unspecified traumatic cataract, bilateral
H26.111 Localized traumatic opacities, right eye
H26.112 Localized traumatic opacities, left eye
H26.113 Localized traumatic opacities, bilateral
H26.121 Partially resolved traumatic cataract, right eye
H26.122 Partially resolved traumatic cataract, left eye
H26.123 Partially resolved traumatic cataract, bilateral
H26.131 Total traumatic cataract, right eye
H26.132 Total traumatic cataract, left eye
H26.133 Total traumatic cataract, bilateral
H26.20 Unspecified complicated cataract
H26.211 Cataract with neovascularization, right eye
H26.212 Cataract with neovascularization, left eye
H26.213 Cataract with neovascularization, bilateral
H26.221 Cataract secondary to ocular disorders (degenerative) (inflammatory), right eye
H26.222 Cataract secondary to ocular disorders (degenerative) (inflammatory), left eye
H26.223 Cataract secondary to ocular disorders (degenerative) (inflammatory), bilateral
H26.231 Glaucomatous flecks (subcapsular), right eye
H26.232 Glaucomatous flecks (subcapsular), left eye
H26.233 Glaucomatous flecks (subcapsular), bilateral
H26.31 Drug-induced cataract, right eye
H26.32 Drug-induced cataract, left eye
H26.33 Drug-induced cataract, bilateral
H26.8 Other specified cataract
H26.9 Unspecified cataract
H27.01 Aphakia, right eye
H27.02 Aphakia, left eye
H27.03 Aphakia, bilateral
H27.111 Subluxation of lens, right eye
H27.112 Subluxation of lens, left eye
H27.113 Subluxation of lens, bilateral
H27.121 Anterior dislocation of lens, right eye
H27.122 Anterior dislocation of lens, left eye
H27.123 Anterior dislocation of lens, bilateral
H27.131 Posterior dislocation of lens, right eye
H27.132 Posterior dislocation of lens, left eye
H27.133 Posterior dislocation of lens, bilateral
H28 Cataract in diseases classified elsewhere
Q12.0 Congenital cataract
Q12.1 Congenital displaced lens
Q12.2 Coloboma of lens
Q12.3 Congenital aphakia
Q12.4 Spherophakia
Q12.8 Other congenital lens malformations
T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter
T85.21XD Breakdown (mechanical) of intraocular lens, subsequent encounter
T85.21XS Breakdown (mechanical) of intraocular lens, sequela
T85.22XA Displacement of intraocular lens, initial encounter
T85.22XD Displacement of intraocular lens, subsequent encounter
T85.22XS Displacement of intraocular lens, sequela
T85.29XA Other mechanical complication of intraocular lens, initial encounter
T85.29XD Other mechanical complication of intraocular lens, subsequent encounter
T85.29XS Other mechanical complication of intraocular lens, sequela
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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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.

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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
09/19/2019 R1

This article was converted to the new Billing and Coding Article type.

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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