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Contractor Information

Contractor Name ^{back to top}

NHIC, Corp.
Contractor Number ^{back to top}
31142
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L12803

LCD Title ^{back to top}
PACHYMETRY OF THE CORNEA

Contractor's Determination Number ^{back to top}
200

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary documentation to process the claim. Title XVIII of the Society Security Act, Section 1842(a)(2)(B) This section requires the carrier to assist physicians/suppliers of services to develop and study utilization practices and their effectiveness; and to assist in the application of safeguards against unnecessary utilization. Title XVIII of the Society Security Act, Section 1862(a)(1)(A) This section states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7)

Primary Geographic Jurisdiction ^{back to top}
Massachusetts Maine New Hampshire Vermont

Oversight Region ^{back to top}
Region I

Original Determination Effective Date ^{back to top}
For services performed on or after 07/15/2003

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 04/01/2006

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Pachymetry is the ultrasonic measurement of the thickness of the cornea. INDICATIONS OF COVERAGE Corneal pachymetry is covered when the test is integral to the medical management decision-making of the patient. AND Corneal pachymetry is covered for the patient who has one of the following conditions: Corneal ectasias, e.g., keratoglobus, pellucid degeneration, and keratoconus. Fuch's endothelial dystrophy or bullous keratopathy. Posterior polymorphous dystrophy. Corneal rejection post- penetrating keratoplasty. Corneal edema. Elevated intraocular pressure in glaucoma suspect when corneal thickness is unknown. Worsening of glaucoma when corneal thickness is unknown Enlarged cup-disc ratio is equal to or greater than 0.3¹ Corneal pachymetry is covered preoperatively for patients scheduled for corneal transplant. Corneal pachymetry is covered postoperatively when the test is performed following corneal transplant. LIMITATIONS OF COVERAGE Corneal pachymetry is not covered unless the test is integral to the medical management decision-making of the patient. Corneal pachymetry is not covered to evaluate refractive errors. Corneal pachymetry is not covered unless the patient has one of the following conditions: Corneal ectasias, e.g., keratoglobus, pellucid degeneration, and keratoconus. Fuch's endothelial dystrophy or bullous keratopathy. Posterior polymorphous dystrophy. Corneal rejection post- penetrating keratoplasty. Corneal edema. Elevated intraocular pressure in glaucoma suspect when corneal thickness is unknown. Worsening of glaucoma when corneal thickness is unknown. Enlarged cup-disc ratios < 0.3 ^1. Corneal pachymetry is not covered preoperatively for patients unless they are scheduled for corneal transplant. Corneal pachymetry is not covered postoperatively unless the test is performed following corneal transplant.

Coding Information

Bill Type Codes: ^{back to top}

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

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

ICD-9 Codes that Support Medical Necessity ^{back to top}

364.22	GLAUCOMATOCYCLITIC CRISES
364.77	RECESSION OF CHAMBER ANGLE OF EYE
365.00	PREGLAUCOMA UNSPECIFIED
365.01	OPEN ANGLE WITH BORDERLINE GLAUCOMA FINDINGS
365.02	ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA
365.03	STEROID RESPONDERS BORDERLINE GLAUCOMA
365.04	OCULAR HYPERTENSION
365.10	OPEN-ANGLE GLAUCOMA UNSPECIFIED
365.11	PRIMARY OPEN ANGLE GLAUCOMA
365.12	LOW TENSION OPEN-ANGLE GLAUCOMA
365.13	PIGMENTARY OPEN-ANGLE GLAUCOMA
365.14	GLAUCOMA OF CHILDHOOD
365.15	RESIDUAL STAGE OF OPEN ANGLE GLAUCOMA
365.20 - 365.24	PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA
365.31	CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE
365.41 - 365.44	GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES
365.51 - 365.59	PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS
365.60	GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER
365.81 - 365.89	HYPERSECRETION GLAUCOMA - OTHER SPECIFIED GLAUCOMA
365.9	UNSPECIFIED GLAUCOMA
371.00	CORNEAL OPACITY UNSPECIFIED
371.10	CORNEAL DEPOSIT UNSPECIFIED
371.11	ANTERIOR CORNEAL PIGMENTATIONS
371.12	STROMAL CORNEAL PIGMENTATIONS
371.13	POSTERIOR CORNEAL PIGMENTATIONS
371.14	KAYSER-FLEISCHER RING
371.15	OTHER CORNEAL DEPOSITS ASSOCIATED WITH METABOLIC DISORDERS
371.16	ARGENTOUS CORNEAL DEPOSITS
371.20	CORNEAL EDEMA UNSPECIFIED
371.21	IDIOPATHIC CORNEAL EDEMA
371.22	SECONDARY CORNEAL EDEMA
371.23	BULLOUS KERATOPATHY
371.50	HEREDITARY CORNEAL DYSTROPHY UNSPECIFIED
371.57	ENDOTHELIAL CORNEAL DYSTROPHY
371.58	OTHER POSTERIOR CORNEAL DYSTROPHIES
371.60	KERATOCONUS UNSPECIFIED
371.61	KERATOCONUS STABLE CONDITION
371.62	KERATOCONUS ACUTE HYDROPS
371.70	CORNEAL DEFORMITY UNSPECIFIED
371.71	CORNEAL ECTASIA
377.14	GLAUCOMATOUS ATROPHY (CUPPING) OF OPTIC DISC
743.10 - 743.12	MICROPHTHALMOS UNSPECIFIED - MICROPHTHALMOS ASSOCIATED WITH OTHER ANOMALIES OF EYE AND ADNEXA
743.20 - 743.22	BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES
743.41 - 743.49	CONGENITAL ANOMALIES OF CORNEAL SIZE AND SHAPE - OTHER CONGENITAL ANOMALIES OF ANTERIOR SEGMENT
996.51	MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT
996.89	COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN

Diagnoses that Support Medical Necessity ^{back to top}

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

All ICD-9 Codes not listed under the “ICD-9 Codes That Support Medical Necessity” section of this policy will be denied

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

General Information

Documentation Requirements ^{back to top}

The documentation should show that the service was reasonable and necessary for at least one of the covered indications of coverage.

The patient’s medical record should be legible, clearly indicate the reasonableness and necessity, and frequency of the service.

Documentation supporting the necessity and frequency of treatment more than once per lifetime must be kept in the patient's medical record and be available to Medicare upon request.

Medical records should be furnished to the Carrier upon request.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Claims for corneal pachymetry will be allowed once per lifetime for the evaluation of the patient who meets the indications of coverage.

Claims for corneal pachymetry, submitted more than once per lifetime for any diagnosis, may be reviewed on a post-payment basis.

Claims for corneal pachymetry, submitted for patients with Fuchs' dystrophy, will be allowed twice per year without medical review. Corneal pachymetry must be used for medical management decision-making.

Corneal pachymetry is covered on a one time basis when performed on an established glaucoma patient.

Claims for corneal pachymetry performed more than once per year in the evaluation of corneal edema, corneal rejection following penetrating keratoplasty, and the endothelial dysfunction of the cornea may be reviewed on a post-payment basis.
The diagnostic test must be used for clinical decision-making and medical management. When corneal pachymetry is used to decide if the patient might undergo cataract surgery without simultaneous penetrating keratoplasty is an example of the use of medical management decision-making. This criteria applies to the following codes:
- 371.20 Corneal edema, unspecified
- 371.22 Secondary corneal edema
- 371.23 Bullous keratopathy
- 371.58 Posterior polymorphous dystrophy
- 996.51 Corneal rejection post penetrating
  keratoplasty

Sources of Information and Basis for Decision ^{back to top}

1.Palmberg, Paul, MD PhD. “Answers from the Ocular Hypertension Treatment Study”, Archives of Ophthalmology: June 2002, Volume 120, p 829-830
2.Carrier Advisory Committee Ophthalmology and Optometry Working Group

Advisory Committee Meeting Notes ^{back to top}

Meeting date 02/10/2003

Start Date of Comment Period ^{back to top}

02/10/2003

End Date of Comment Period ^{back to top}

03/26/2003

Start Date of Notice Period ^{back to top}

06/01/2003

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

R7
04/01/2006

Revised Utilization Guildeline section as follows:

Claims for corneal pachymetry will be allowed once per lifetime for the evaluation of the patient who meets the indications of coverage.

Claims for corneal pachymetry, submitted more than once per lifetime for any diagnosis, may be reviewed on a post-payment basis.

Claims for corneal pachymetry, submitted for patients with Fuchs' dystrophy, will be allowed twice per year without medical review. This diagnostic test must be used for medical management decision-making.

Claims for corneal pachymetry performed more than once per year in the evaluation of corneal edema, corneal rejection following penetrating keratoplasty, and the endothelial dysfunction of the cornea may be reviewed on a post-payment basis.
The diagnostic test must be used for clinical decision-making and medical management. When corneal pachymetry is used to decide if the patient might undergo cataract surgery without simultaneous penetrating keratoplasty is an example of the use of medical management decision-making. This criteria applies to the following codes:
- 371.20 Corneal edema, unspecified
- 371.22 Secondary corneal edema
- 371.23 Bullous keratopathy
- 371.58 Posterior polymorphous dystrophy
- 996.51 Corneal rejection post penetrating
  keratoplasty

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

05/01/2007

Medicare Coverage Database

LCD for PACHYMETRY OF THE CORNEA (L12803)