Ophthalmology (ophthal)

By Steve Ross,2014-04-26 19:56
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Ophthalmology (ophthal)


    Ophthalmology 1

This section describes program information and billing policies for ophthalmology services.

Correct Claim Form Ophthalmological services can be billed on either a CMS-1500 or

    UB-04 (outpatient providers) claim form. The following

    ophthalmological and eye appliance procedure codes, however, must

    be billed only on the CMS-1500:

     CPT-4 codes: 68761, 92002 92060, 92070 92284,

    92310 92353, 92370, 92371 and 92499

     HCPCS codes: S0500, S0512, S0514, S0516, V2020 V2499,

    V2500, V2501, V2510, V2511, V2513 V2521, V2523, V2599,

    V2600 V2615, V2623 V2629, V2702 V2718, V2744 V2755,

    V2760 V2770, V2781 V2784 and V2799

    Modifiers Ophthalmological services and eye appliances (frames, lenses,

     contact lens, etc.) must be billed with the appropriate modifier(s).

     Vision care modifiers are listed in the Modifiers for Vision Care

    Services section of the Part 2 Vision Care manual.

2 Ophthalmology October 2009



    Unilateral and Bilateral The CPT-4 90000 series of codes for eye procedures are considered bilateral services. Therefore, a code should be billed only once, regardless of whether one or both eyes were involved. However, in the case of eye surgeries, this does not apply, and the appropriate code should be used to specify whether the procedure was unilateral or bilateral.

    The following codes may be billed as unilateral or bilateral services.

    CPT-4 Code Description

    92132 Scanning computerized ophthalmic diagnostic

    imaging, anterior segment, with interpretation

    and report

    92133 Scanning computerized ophthalmic diagnostic

    imaging, posterior segment, with

    interpretation and report; optic nerve

    92133 retina

    92225 Ophthalmoscopy, extended, with retinal

    drawing [eg, for retinal detachment,

    melanoma], with interpretation and report;


    92226 subsequent

    92227 Remote imaging for detection of retinal

    disease (eg, retinopathy in a patient with

    diabetes) with analysis and report

    * 92228 Remote imaging for monitoring and

    maintenance of active retinal disease (eg,

    diabetic retinopathy) with physician review,

    interpretation and report

    92230 Fluorescein angiography with interpretation

    and report

    92235 Fluorescein angiography [includes multiframe

    imaging] with interpretation and report

     When performed as a unilateral procedure these procedures must be billed with a quantity of “1” and either modifier LT (left side) or RT (right side) to indicate the side of the body on which the procedure is performed.

     When performed as a bilateral procedure, claims must be billed on a single line using modifier 50 (bilateral procedure) with a quantity of “2.”

    * Note: This code is split-billable and must be billed with the

    appropriate modifiers (26, TC or ZS)

    2 Ophthalmology March 2012



    Ophthalmic CPT-4 code 92135 (scanning computerized ophthalmic diagnostic Diagnostic Imaging: imaging [eg, scanning laser] with interpretation and report, unilateral) Billing Restrictions is not reimbursable when billed for the same recipient, by the same

    rendering provider, for the same date of service as the following


    CPT-4 Code Description

    76512 B-scan (with or without superimposed

    non-quantitative A-scan)

    92225 Ophthalmoscopy, extended, with retinal drawing

    (eg, for retinal detachment, melanoma), with

    interpretation and report; initial

    92226 subsequent

    92250 Fundus photography with interpretation and report

ICD-9-CM Diagnosis Refer to the Ophthalmology: Diagnosis Codes section in this manual

    Code Requirements for ICD-9-CM diagnosis codes that must be billed in conjunction with

    code 92135.

    Corneal Pachymetry CPT-4 code 76514 is payable only once-in-a-lifetime when billed with

    the glaucoma-related diagnosis codes indicated in the Professional

    Services: Diagnosis Code section in this manual. Refer to the

    Radiology: Diagnosis Ultrasound section for the ICD-9-CM diagnosis

    codes to bill in conjunction with code 76514 for payment, in the

    appropriate Part 2 manual.

    2 Ophthalmology January 2009



    Computerized Computerized corneal topography (CPT-4 code 92025) is Corneal Topography reimbursable to optometrists within their scope of practice. It requires

    medical review.

    When billing for code 92025, providers must document in the

    Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the

    claim or on an attachment that the service was performed according

    to one of the following criteria:

    ; Pre- or post-operatively for corneal transplant (codes 65710,

    65730, 65750, 65755 and 65756)

    ; Pre- or post-operatively prior to cataract surgery due to

    irregular corneal curvature or irregular astigmatism

    ; In the treatment of irregular astigmatism as a result of corneal

    disease or trauma

    ; To assist in the fitting of contact lenses for patients with

    corneal disease or trauma (ICD-9-CM diagnosis codes 371


    ; To assist in defining further treatment

    This procedure is not covered under the following conditions:

    ; When performed pre- or post-operatively for non-Medi-Cal

    covered refractive surgery procedures such as codes 65760

    (kerato mileusis), 65765 (keratophakia), 65767

    (epikeratoplasty), 65771 (radial keratotomy), 65772 (corneal

    relaxing incision) and 65775 (corneal wedge resection)

    ; When performed for routine screening purposes in the absence

    of associated signs, symptoms, illness or injury

    Billing Requirements CPT-4 code 92025 must be billed with the appropriate modifiers

    (26, 99, TC or ZS).

2 Ophthalmology September 2009



    Ranibizumab (Lucentis?) Ranibizumab (HCPCS code J2778) is reimbursable with an approved Treatment Authorization Request (TAR) for the treatment of exudative

    senile macular degeneration (ICD-9-CM diagnosis code 362.52) or macular edema following retinal vein occlusion (primary ICD-9-CM code 362.83) with a secondary ICD-9-CM code of either 362.35 (central retinal vein occlusion) or 362.36 (venous tributary [branch] occlusion).

    Note: When a TAR is requested for the treatment of exudative senile

    macular degeneration, providers must include medical

    justification for the use of ranibizumab over bevacizumab (e.g.,

    potential higher relative risks and adverse effects, etc.).

    Reimbursement is limited to 12 injections per eye, per year. When 12 injections are requested for the treatment of exudative senile macular degeneration, providers must indicate the reason ranibizumab cannot be given as needed with monthly evaluation. Appropriate site modifiers for this code are LT, RT or 50 if bilateral. Code J2778 must be billed on the same claim as CPT-4 code 67028 (intravitreal injection of a pharmacologic agent).

     ?) Bevacizumub, 10 mg (HCPCS code J9035), is reimbursable for the Bevacizumab (Avastin

    treatment of exudative senile macular degeneration (ICD-9-CM code 362.52) by intravitreal injections.

    In addition to billing with ICD-9-CM code 362.52, providers must submit the following documentation in the Reserved for Local Use

    field (Box 19) of the claim or on a separate attachment:

    ; Notation of the eye being treated, right, left or both.

    ; Indication for treatment; choroidal neovascularization (CNV), or

    macular edema, or pigment epithelial detachment secondary to

    wet age-related macular degeneration (AMD).

    ; History of progressive visual loss or worsening of anatomic

    appearance as determined by fluorescein angiography, optical

    coherence tomography (COT) or scanning computerized

    ophthalmic diagnostic imaging

    Treatments are limited to 12 intravitreal injections of bevacizumab per year per eye.

    HCPCS code J9035 descriptor denotes 10 mg of bevacizumab. Current literature indicates anticipated dosage is 1.25 mg or less when used off-label in the eye to treat exudative senile macular degeneration. Providers may bill for the quantity that is equal to the amount given to the patient plus the amount wasted. However, Medi-Cal will pay no more than one unit (10 mg) per patient, per date of service when bevacizumab is used for the treatment of exudative senile macular degeneration. This limitation does not apply to FDA-approved indications of bevacizumab.

    2 Ophthalmology June 2011



“By Report” In some situations it may be necessary to bill “By Report” – include a

    Procedures brief report that justifies the procedure.

     The following CPT-4 codes require medical justification. Claims for

    these procedures will suspend for medical review and/or manual

    pricing. Justification includes, but is not limited to: the patient’s

    diagnosis and associated symptoms, a short explanation of why the

    visit was necessary, a summary of services performed and the

    outcome and a statement of the treatment plan that indicates whether

    a referral was made.

    CPT-4 Code Description

    65210 Removal of foreign body, external eye;

    conjunctival embedded

    67938 Removal of embedded foreign body, eyelid

    68761 Closure of the lacrimal punctum

    68801 Dilation of the lacrimal punctum

    92018 Ophthalmological examination and evaluation,

    under general anesthesia, with or without

    manipulation of globe for passive range of

    motion or other manipulation to facilitate

    diagnostic examination; complete

    92019 limited

    92025 Computerized corneal topography, unilateral or

    bilateral, with interpretation and report

    92100 Serial tonometry

    92225 Extended ophthalmoscopy

    92250 Fundus photography with interpretation and


    92310 92312 Contact lens evaluations

    92499 Unlisted ophthalmological service or procedure

2 Ophthalmology September 2009



Routine Claims by either an ophthalmologist or optometrist for routine

    Examinations comprehensive eye examinations (CPT-4 codes 92004 [new patient]

    and 92014 [established patient]) are covered once every two years for

    recipients of any age.

    Determination of When performed, determination of refractive state (CPT-4 code Refractive State 92015) must be separately reported when billed in conjunction with

    CPT-4 code 92004 or 92014.

     Code 92015 is considered typical postoperative follow-up care

    included in the surgical package for cataract extraction surgeries.

    Therefore, this service is not reimbursable when billed in conjunction

    with or within the 90-day post follow-up period of CPT-4 codes 66840,

    66850, 66852, 66920, 66930, 66940 and 66982 66985.

    Tonometry Tonometry services are included in an eye examination and should

    not be billed as a separate procedure.

    Note: This is a one-time measurement and not serial tonometry.

    Diagnostic Drugs The use of topically applied diagnostic drugs (cycloplegic, mydriatic or

    anesthetic topical pharmaceutical agents) is included in the

    reimbursement of ophthalmological procedures.

2 Ophthalmology October 2008



    Interim Examinations A second eye examination with refraction within 24 months is covered

    only when a sign or symptom indicates a need for this service.

    Claims billed with CPT-4 codes 92004 and 92014 must include the

    appropriate ICD-9-CM code that justifies the examination in (Box 67)

    of the UB-04 claim form or Nature of Illness or Injury field (Box 21) of

    the CMS-1500 claim. This policy applies whether the claim is

    submitted by the provider of the prior examination or by a different

    provider. Refer to the Professional Services: Diagnosis Codes

    section in the Part 2 Vision Care manual for a list of required

    ICD-9-CM diagnosis codes when billing for interim comprehensive

    eye examinations within the 24-month benefit period.

E&M Codes Not Evaluation and Management (E&M) visit codes (CPT-4 codes

    Reimbursable With 99201 99215) should not be billed with eye examination codes Eye Examination (CPT-4 codes 92002, 92004, 92012 and 92014) by the same provider,

    Services for the same recipient and date of service. Reimbursement for

    duplicate services will be reduced or denied.

2 Ophthalmology January 2008



    Medicare-Covered Services Eye examinations for Medicare/Medi-Cal-eligible recipients must be

    billed to Medicare prior to billing Medi-Cal for the following claims:

    ; Examinations performed in conjunction with eye disease (such

    as glaucoma or cataract) or eye injury

    ; Interim examinations for recipients with a sign or symptom that

    justifies the need for an examination (providers must include

    the principal ICD-9-CM diagnosis code on the claim)

    Medicare Non-Covered Routine examinations for the purpose of prescribing, fitting or

    changing eyeglasses, as well as eye refractions, are not covered by

    Medicare. Eye examination claims (CPT-4 codes 92002, 92004,

    92012 and 92014) for Medicare/Medi-Cal-eligible recipients with only

    diagnoses for disorders, refraction, accommodation and color vision

    deficiencies may be billed directly to Medi-Cal. The recipient’s

     primary ICD-9-CM diagnosis code must be entered in the Principal

    Diagnosis Code field (Box 67) of the UB-04 claim form or Diagnosis

    or Nature of Illness or Injury field (Box 21) of the CMS-1500 claim


     Determination of refractive state (CPT-4 code 92015) is not covered

    by Medicare and may be billed directly to Medi-Cal.

    Refer to the Medicare Non-Covered Services: CPT-4 Codes section in

    this manual for a list of ICD-9-CM diagnosis codes that may be

    submitted directly to Medi-Cal in conjunction with CPT-4 codes 92002,

    92004, 92012 and 92014.

    Hard Copy Billing Claims that do not automatically cross over electronically from Crossover Claims Medicare carriers must be hard copy billed to the the Department of

     Healthcare Services (DHCS) Fiscal Intermediary (FI) Crossover Unit

     on a CMS-1500 claim form. Refer to the Medicare/Medi-Cal

     Crossover Claims: Vision Care section in the appropriate Part 2

     manual for detailed crossover billing information.

    Providers must attach a copy of the Explanation of Medicare Benefits

    (EOMB)/Medicare Remittance Notice (MRN) to all crossover claims.

    Refractive services (CPT-4 code 92015) may be billed directly to


2 Ophthalmology November 2009



    Contact Lenses Claims billed with CPT-4 codes 92310 (prescription of optical and

    physical characteristics of and fitting of contact lenses, with medical

    supervision of adaptation; corneal lens, both eyes, except for

    aphakia), 92311 (…corneal lens for aphakia, one eye) and 92312

     (…corneal lens for aphakia, both eyes) require authorization (a

    Treatment Authorization Request) from the Department of Health

     Care Services (DHCS) Vision Care Policy Unit (VCPU). Refer to the

    Contact Lenses and TAR Completion for Vision Care sections in the

    Part 2 Vision Care manual for policy and billing instructions.

    Modifiers 22 and SC Providers can only use modifiers 22 and SC when billing for CPT-4

    codes 92310 92312.

Required Information The following information is required in the Medical Justification field

    of the 50-3 Treatment Authorization Request (TAR) form or on a

     separate attachment. For additional information about the

     authorization process, refer to the TAR Completion for Vision Care

     section in the Part 2 Vision Care manual.

    ; Valid diagnosis or condition that precludes the satisfactory

    wearing of conventional eyeglasses, including documentation

    of clinical data when possible

    ; Best corrected visual acuities through eyeglasses and contact


    ; Identification of the contact lens to be used by trade or

    manufacturer’s name, base curve, diameter and power

    ; For a diagnosis of aniseikonia (ICD-9-CM code 367.32), a

    statement that indicates why eyeglasses cannot be used and

    supporting clinical data. (Anisometropia greater than three

    diopters, coupled with the presence of symptoms commonly

    associated with aniseikonia can qualify contact lenses for

    authorization. Where a smaller degree of anisometropia is

    present, detailed justification is required.)

    ; For conditions where contact lenses are the only option, a

    statement of the chronic pathology or deformity of the nose,

    skin or ears that precludes the wearing of conventional


    ; If extended wear contact lenses are prescribed, justification of

    why conventional, disposable or plan replacement extended

    wear lenses rather than daily wear lenses are necessary.

    (When infirmity is a pertinent factor in the decision, a

    statement that demonstrates the immediate availability of

    someone to assist the recipient in lens insertion, centering and

    removal is required.)

    ; A statement that indicates whether a recipient has worn contact

    lenses in the past

2 Ophthalmology January 2008

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