Article for Corneal Pachymetry - Supplemental Instructions Article (A48393)


Contractor Information

Contractor Name 
National Government Services, Inc. 
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


Article Information

Article ID Number 
A48393 
Article Type 
Article
Key Article 
Yes
Article Title 
Corneal Pachymetry - Supplemental Instructions Article 
AMA CPT / ADA CDT Copyright Statement 
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.
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Original Article Effective Date 
07/18/2008
Article Revision Effective Date 
04/01/2010
Article Text 
The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Corneal Pachymetry. The LCD can be accessed through our contractor Web site at www.NGSMedicare.com. It can also be found on the Medicare Coverage Database at www.cms.hhs.gov/mcd.

Coding Guidelines:

General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC:


Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

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-9-CM diagnosis 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, Fiscal Intermediary (FI) and 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 Fiscal Intermediary or Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) 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, FI and 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.


CPT code 92499 (unlisted ophthalmological service or procedure) should be used to report optical pachymetry services. The phrase, "Optical Pachymetry" should be listed in the narrative note in item 19 of the CMS 1500 form or electronic equivalent for claims submitted to Part B, and in FL 80 for claims submitted to Part A. The optical pachymetry service should be billed and is valued equivalently to the ultrasonic service (CPT code 76514). Modifier RT, LT, or 50 (bilateral) should be reported with CPT code 92499, as appropriate.

CPT code 76514 is reimbursed as a bilateral service (both eyes are included in a single test). Therefore, it should be billed once (one unit of service) regardless of whether it was performed on one or two eyes. If the service is performed unilaterally, report modifier RT or LT and modifier 52 (reduced services) on the claim.

For claims submitted to the carrier or 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 corneal pachymetry, CPT 76514 and 92499, are payable under Part B in the following places of service:

The global service: office (11), assisted living facility (13), urgent care facility (20), nursing facility (32), custodial care facility (33), and independent clinic (49).

The technical component (modifier TC): office (11), assisted living facility (13), urgent care facility (20), nursing facility (32), custodial care facility (33), independent clinic (49), federally qualified health center (50) and rural health clinic (72).

The professional component (modifier 26): office (11), assisted living facility (13), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), emergency room-hospital (23), ambulatory surgical centers (24), skilled nursing facility (31), nursing facility (32), custodial care facility (33) and independent clinic (49).

For claims submitted to the fiscal intermediary or Part A MAC:

Hospital Inpatient Claims:
  • The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
  • The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  • For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
  • The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
  • The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.


Coding Information

Bill Type Codes: 

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article 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)
18x Hospital-swing beds
21x SNF-inpatient, Part A
22x SNF-inpatient or home health visits (Part B only)
23x SNF-outpatient (HHA-A also)
71x Clinic-rural health
73x Clinic - Free-standing
77x Clinic - Federally Qualified Health Center (FQHC)
85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)
 
Revenue Codes: 

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

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

0402 Other imaging services-ultrasound
0972 Professional fees-radiology diagnostic
 
CPT/HCPCS Codes 
CPT code 92499 should be used to report optical pachymetry.
76514 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS)
92499 UNLISTED OPHTHALMOLOGICAL SERVICE OR PROCEDURE
 
ICD-9 Codes that are Covered 
Please see LCD.
 
ICD-9 Codes that are Not Covered 
Not applicable
 


Other Information

Other Comments 
These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
Revision History Explanation 
Article published April 2010: Bill type 77x added for FQHC services. Limitation of liability guidelines revised in accordance with CMS Transmittals 1840 and 1921. Minor formatting changes made.

Article published December 2009: Place of service 20 (urgent care facility) added to list of payable places of service under Part B; Information added on bill type for reporting FQHC services; minor formatting changes made.

Article published July 2009: The existing LCD and SIA were resubmitted to all NGS Part A and Part B jurisdictions for public and CAC comment from 01/08/2009 through 02/21/2009. In addition to the J13 MAC contracts for which it was already in effect, these instructions now apply to all NGS contracts listed under Primary Geographic Jurisdiction. Changes include: coding guidelines added for reporting optical pachymetry, payable places of service expanded for global and technical services to include assisted living facility (13), nursing facility (32), custodial care facility (33), and skilled nursing facility (for the professional component only). Article title changed to “Corneal Pachymetry - Supplemental Instructions Article”. Article renumbered from A47565 to A48393.

This LCD is effective for Downstate New York – Part B on July 18, 2008; for Connecticut – Part B on August 1, 2008; for Upstate New York – Part B on September 1, 2008; for New York and Connecticut – Part A on November 14, 2008.

The CMS Statement of Work for the J13 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This First Coast Service Options policy is being promulgated to the J13 MAC as the most clinically appropriate LCD within that jurisdiction.

3/7/2010 - The description for Bill Type Code 73 was changed
 
Related Documents 
LCD(s)
L28142 - Corneal Pachymetry