Local Coverage Determination (LCD)

Corneal Pachymetry

L33630

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33630
Original ICD-9 LCD ID
Not Applicable
LCD Title
Corneal Pachymetry
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/12/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End 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.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:

CMS Publication Pub. 100-08, Program Integrity Manual, Chapter 13:

    13.5.1 Reasonable and Necessary Provisions in LCDs.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Corneal Pachymetry is the measurement of corneal thickness and commonly uses either ultrasonic or optical methods. Measurement of corneal thickness in individuals presenting with increased intraocular pressure assists in determining if there is a risk of glaucoma or if the individual's increased eye pressure is the result of abnormal corneal thickness. The test must be integral to the medical management decision-making of the patient. Coverage is limited to ophthalmologists and optometrists.

Indications and Limitations:

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed to determine the amount of endothelial trauma sustained during surgery, assessment of the health of the cornea pre-operatively in Fuch's dystrophy, post ocular trauma and for the assessment of corneal thickness or (in suspected glaucoma) following the diagnosis of increased intraocular pressure prior to the initiation of a treatment regimen for glaucoma. It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma or surgery.

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed only by ophthalmologist and optometrists.

Medicare will not pay for use of pachymetry when used in preparation for surgery to reshape the cornea of the eye for the purpose of correcting visual problems (refractive surgery), such as myopia (nearsightedness) and hyperopia (farsightedness).

Whether patients have been previously diagnosed and are under treatment for glaucoma or are newly diagnosed, pachymetry will be covered once per lifetime, or more frequently in cases where there has been surgical or non-surgical trauma.

When there is a question of corneal disease supported by diagnosis, then pachymetry may be performed at the same time as endothelial cell count.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information
N/A
Bibliography

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Albert DM, Jakobiac FA. Principles and Practice of Ophthalmology (2nd ed.) WB Saunders. 2000. (This reference was used to gain textbook knowledge of the cornea.)

Bohnke M, Mojon DS, Sobottka AC. Central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. Br. J. Ophthalmology. 2001;85:792-795.

Brandt J. Corneal thickness in glaucoma screening, diagnosis and management. Current Opinion in Ophthalmology. 2004;15:85-89.

Chen P, Kim J. Central corneal pachymetry and visual field progression in patients with open-angle glaucoma. Ophthalmology. 2004;111:2126-2132.

Herndon L, Stinnet S, Weizer J. Central corneal thickness as a risk factor for advanced glaucoma damage. Archives of Ophthalmology. 2004;122,:17-21.

Ho T, Cheng ACK, Rao SK, Lau S, Leung CKS, Lam DSC. Central corneal thickness measurements using Orbscan II, Visante, ultrasound, and Pentacam pachymetry after laser in situ keratomileusis for myopia. Ophthalmology Review. 2007;33(7):1177-1182.

Kass MA, Heuer DK, Higginbotham EJ, et al. The ocular hypertension treatment study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Archives of Ophthalmology. 2002;120:701-711. (This reference provided data which supported that ocular hypertension may be the result of abnormal corneal thickness.)

Kim HY, Budenz DL, Lee PS, Feuer WJ, Barton K. Comparison of central corneal thickness using anterior segment optical coherence tomography vs ultrasound pachymetry. Am J Ophthalmology. 2008;145(2):228-232.

Leung DYL, Lam KT, Yeung BYM, Lam DSC. Comparison between corneal thickness measurements by ultrasound pachymetry and optical coherence tomography. Clinical & Experimental Ophthalmology. 2006;34(8):751-754.

Medeiros FA, Sample PA, Zangwill LM, Bowd C, Aihara M, Weinreb RN. Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. American Journal of Ophthalmology. 2003;136:805-813.

Nemuesure B, Wu S, Hennis A, Leske CM. Corneal thickness and intraocular pressure in the Barbadoes eye studies. Archives of Ophthalmology. 2003;121:240-244. (This reference provided information regarding subjects determined to have increased corneal thickness and its relationship to increased ocular pressure.)

Shih C, Trokel S, Tsai J, Zivin J. Clinical significance of central corneal thickness in the management of glaucoma: Archives of Ophthalmology. 2004;122:1270-1275.

Wang J, Fonn D, Simpson TL, Jones L. Relation between optical coherence tomography and optical pachymetry measurements of corneal swelling induced by hypoxia. Am J Ohpthalmology. 2002;134(1);93-98.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/12/2019 R9

This LCD has been converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R8

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56548. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
06/15/2019 R7

Added the following ICD-10-CM diagnosis codes to the "ICD-10 Codes that Support Medical Necessity" section: H18.221, H18.222, H18.223, H18.231, H18, 232, H18.233 and deleted diagnosis code H18.20, effective for services rendered on or after June 15. 2019.  

DATE (06/15/2019): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/01/2017 R6

Added ICD-10-CM diagnosis code  H40.1420 to Group 1 to support medical necessity, effective for services rendered on or after 10/01/2015.

DATE (08/01/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
10/01/2016 R5 Added H40.1110 to the ICD-10 Codes that Support Medical Necessity section due to the annual ICD-10-CM update.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R4 Added multiple 2017 ICD-10-CM codes to the ICD-10 Codes that Support Medical Necessity section, due to the annual ICD-10-CM update.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R3 Added ICD-10-CM diagnosis code range H40.10X1-H40.10X4 to Group 1 to support medical necessity, effective for services rendered on or after 10/01/2015.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R2 Bill type codes added
  • Provider Education/Guidance
10/01/2015 R1 Added the following ICD-10-CM codes to the ICD-10 Codes that Support Medical Necessity section: T85.318D, T85.318S,
T85.328D, T85.328S, T85.398D, T85.398S.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56548 - Billing and Coding: Corneal Pachymetry
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/05/2019 09/12/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Cornea
  • Ophthalmology
  • Eye

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