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CPT Code: 76514  Region: 37

States covered:  General guidelines if your state does not have a local coverage determination

Title:  Corneal Pachymetry

Category
Ophthalmic Ultrasound

Description
Corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

DISCLAIMER

This Medicare carrier does not have a local coverage determination (LCD) for corneal pachymetry.  The policy presented is a sample and it is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.  

FEE SCHEDULE



PROCEDURE DESCRIPTION

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.

CLINICAL INDICATIONS

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed to determine:

• The amount of endothelial trauma sustained during surgery involving the cornea
• Preoperative assessment of the health of the cornea in Fuch’s dystrophy
• Assessment of corneal thickness after ocular trauma
• Assessment of corneal thickness in suspected glaucoma following the diagnosis of increased intraocular pressure AND prior to the initiation of a treatment regimen for glaucoma.

Medicare will consider corneal pachymetry to be medically necessary and reasonable when performed only by ophthalmologists 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).  When the change in the corneal shape results from a previous partial or complete corneal transplant, Medicare will cover a pachymetry service.

COVERED DIAGNOSES

ICD-10 Diagnosis Codes:




DOCUMENTATION REQUIREMENTS

Medical record documentation maintained by the ordering/referring physician should indicate the medical necessity for performing the test and the test results.  This information is usually found in the history and physical, office/progress notes, or test results.

If the provider of the service is other than the ordering/referring physician, that provider should maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies.  The physician should state the clinical indication/medical necessity for the study in the order for the test.

Documentation should contain a history and physical which supports the diagnosis for which this service is being rendered.  Documentation should be legible, relevant and sufficient to justify the services billed.  

This documentation must be made available to Medicare upon request.

CODING GUIDELINES

Report a corneal pachymetry measurement with CPT code 76514. 

UTILIZATION GUIDELINES

It would be expected that these services be performed as indicated by current medical literature and/or standards of practice.  When services are performed in excess of established parameters, they may be subject to review for medical necessity.

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