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| LCD Information |
| LCD ID Number back to top |
| L30264 |
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| LCD Title back to top |
| Pachymetry of the Cornea |
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| Contractor's Determination Number back to top |
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| AMA CPT / ADA CDT Copyright Statement back to top |
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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.
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| 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)
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| Primary Geographic Jurisdiction back to top |
Maine
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| Oversight Region back to top |
Region I
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| Original Determination Effective Date back to top |
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For services performed on or after
10/05/2009
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| Original Determination Ending Date back to top |
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| Revision Effective Date back to top |
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For services performed on or after
10/05/2009
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| Revision Ending Date back to top |
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| 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 0.3 1
- 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.
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| 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. |
| 12x |
Hospital-inpatient or home health visits (Part B only) |
| 13x |
Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
| 21x |
SNF-inpatient, Part A |
| 71x |
Clinic-rural health |
| 73x |
Clinic-independent provider based FQHC (eff 10/91) |
| 85x |
Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
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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. |
| 0409 |
Other imaging services-other |
| 0450 |
Emergency room-general classification |
| 051X |
Clinic-general classification |
| 052X |
Free-standing clinic-general classification |
| 0962 |
Professional fees-ophthalmology |
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| CPT/HCPCS Codes back to top |
| 76514 |
OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS) |
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| 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 |
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365.20 - 365.24
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PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED - RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA |
| 365.31 |
CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE |
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365.41 - 365.44
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GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES |
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365.51 - 365.59
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PHACOLYTIC GLAUCOMA - GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS |
| 365.60 |
GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER |
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365.81 - 365.89
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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 |
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743.10 - 743.12
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MICROPHTHALMOS UNSPECIFIED - MICROPHTHALMOS ASSOCIATED WITH OTHER ANOMALIES OF EYE AND ADNEXA |
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743.20 - 743.22
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BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES |
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743.41 - 743.49
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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 |
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| Diagnoses that Support Medical Necessity back to top |
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| 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
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| ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation back to top |
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| Diagnoses that DO NOT Support Medical Necessity back to top |
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| 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.
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| Appendices back to top |
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| 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
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| 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 |
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| Advisory Committee Meeting Notes back to top |
06/15/2009
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| Start Date of Comment Period back to top |
| 06/15/2009 |
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| End Date of Comment Period back to top |
| 07/30/2009 |
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| Start Date of Notice Period back to top |
| 08/20/2009 |
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| Revision History Number back to top |
R2
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| Revision History Explanation back to top |
R2
10/05/2009
This LCD has gone through the CAC process and is effective for services rendered on or after 10/05/2009 for both Part A and Part B, J14- MAC.
R1
06/01/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Carrier Contractor Numbers 31142-ME, 31143-MA,31144-NH,and 31145-VT were removed from this Draft LCD because the NHIC, Corp. J14 MAC Contractor numbers for the States of ME, MA, NH, and VT will be effective for services rendered on or after 06/01/2009. |
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| Reason for Change back to top |
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| Last Reviewed On Date back to top |
| 08/11/2009 |
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| Related Documents back to top |
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This LCD has no Related Documents.
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| LCD Attachments back to top |
| There are no attachments for this LCD. |
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| All Versions back to top |
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Updated on 08/13/2009 with effective dates 10/05/2009 - N/A
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Page Last Modified: 11/30/2009 8:47:16 AM
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