76519_R24

The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD.  This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.  This documentation should include at a minimum the patient’s name and date of service, the indications for testing, an order for testing, the results of testing, and the IOL power calculation. Documentation must be available to Medicare upon request.

Ophthalmic biometry using A-scans (76519) and optical coherence biometry (92136) for the same patient should not be billed by the same provider/physician/group during a 12-month period.  Claims for either of these services in excess of these parameters will not be considered medically necessary.

The technical portion of either 76519 or 92136 and the respective interpretations for the same patient should not be billed more than once during a 12 month period by the same provider/physician/group unless there is a significant change in vision.  Claims in excess of these parameters will not be considered medically necessary.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnoses code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.  For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file.  Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎  The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed.  For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues.  An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier.  An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries.  Services with modifier GY will automatically deny.

Specific coding guidelines for this policy:

Currently, the Medicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is “2” for the global and technical components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136).  The definition of “2” is as follows:

• 2 = 150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.

When the MPFSDB bilateral surgery indicator is “2,” the relative value units (RVUs) are based on the procedure performed on each eye.

• The global service includes the bilateral technical component (76519-TC or 92136-TC) and a unilateral professional service (76519-26 or 92136-26).  The anatomic modifier (-RT or -LT) should be used to indicate the eye on which the professional component was performed.
• The technical component should not be billed with the bilateral modifier -50.  Payment is based on the lower of the submitted charge or the fee schedule for a single code.  No additional payment is made when code 76519-TC or 92136-TC is billed with the bilateral modifier -50.
• If the technical portion of the procedure is only performed on one eye, the -52 modifier for reduced services should be used as well as the appropriate anatomic modifier (-RT or -LT).

Currently, the Medicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is “3” for the professional components of each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of “3” is as follows:

• 3= The usual payment adjustment for bilateral procedures does not apply.  If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.

When the MPFSDB bilateral surgery indicator is “3,” the RVUs are calculated based on the procedure being performed as a unilateral procedure on each eye.  Payment is based on the lower of the submitted charge or 100% of the fee schedule amount for each eye.

• It is not uncommon for an IOL implant to be required for both eyes.  When surgery for bilateral cataracts is scheduled several weeks apart, bill the professional component only when the IOL calculation is done within a timeframe that it can be used for the second planned surgery.
• When the scan is performed and the calculation done on the first eye, bill the technical portion on one line (76519-TC or 92136-TC) and the professional component on a second line [76519 26-RT (or 26-LT) or 92136 26-RT (or 26-LT)].
  • Alternatively, bill the global code and use modifier -RT or -LT to indicate on which eye the professional component was performed [76519-RT (or -LT) or 92136-RT (or –LT)].  Do not submit modifier -50.
• If the technical and professional components are performed on both eyes on the same date, bill the global service on one line and the second professional component on a second line, indicating the anatomic modifier (-LT/-RT) for the second eye.
• One physician may do the technical component and another physician the professional component.  Each will need to use the appropriate modifier, e.g., -TC (technical component) or -26 (professional component).  The professional component should also have the anatomic modifier (-LT/-RT) appended.

For claims submitted to the Part B MAC:

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

Claims for intraocular lens power calculation services are payable under Medicare Part B in the following places of service:

• The global is payable in the office (11) and independent clinic (49) for CPT codes 76519 and 92136.
• The technical component is payable in the office (11); independent clinic (49); federally qualified health center (50); and rural health clinic (72) for CPT codes 76519 and 92136.
• The professional components are payable in the office (11), off campus-outpatient hospital (19), inpatient hospital (21), on campus-outpatient hospital (22), ambulatory surgical center (24) and independent clinic (49) for 76519 and 92136.

The National Correct Coding Initiative (NCCI) may include edits for these CPT codes.  Currently, NCCI edits for CPT codes 76519 and 92136 are as follows:

• Procedure code 76519 includes services performed for procedure 76516.  Separate reimbursement will not be made for 76516 when billed with 76519;
• Payment for 76519 and 92136 for the same patient, same provider, same day will not be made.

The technical component of the scan will generally provide valid information for twelve months.  A repeat scan in less than twelve months would not be covered without documentation of significant change in vision (unless required because a second unaffiliated surgeon performed the second cataract extraction).  Generally, when bilateral cataracts are noted at examination, extraction of the second cataract is only performed after results of the first cataract extraction are known and symptoms or findings support the medical necessity for removal of the cataract in the other eye.  If ophthalmic biometry is performed and later the surgery is canceled, it is reasonable to allow a repeat scan if significant time, e.g., greater than one (1) year, has elapsed when surgery is rescheduled.

Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and surgeon.  If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary.  If the biometry is repeated by the operating surgeon due to inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.