L29122-LCD

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Local Coverage Determination (LCD) for Computerized Corneal Topography (L29122)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29122

LCD Title

Computerized Corneal Topography

Contractor's Determination Number 92025

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 80.7

Indications and Limitations of Coverage and/or Medical Necessity

Computerized Corneal Topography (also known as computer-assisted video keratography (CAVK) and corneal mapping is a computer assisted diagnostic imaging technique in which a special instrument projects a series of light rings on the cornea, creating a color coded map of the corneal surface as well as a cross-section profile. This service is used to provide a detailed map or chart of the physical features and shape of the anterior surface of the cornea. This permits a more accurate portrayal of the physical state of the cornea and the subtle detection of corneal surface irregularity and astigmatism.

Keratoplasty that treats specific lesions of the cornea, such as phototherapeutic keratectomy that removes scar tissue from the visual field, deals with an abnormality of the eye and is not cosmetic surgery. Such cases may be covered under §1862(a)(1)(A) of the Act (CMS Pub 100-03, Chapter 1, Part 1, Section 80.7.1).

FCSO Medicare will consider Computerized Corneal Topography medically necessary under any of the following conditions:

• pre-operatively for evaluation of irregular astigmatism prior to cataract surgery

• monocular diplopia

• bullous keratopathy

• post surgical or post traumatic astigmatism, measuring at a minimum of 3.5 diopters;

• post penetrating keratoplasty surgery;

• post surgical or post traumatic irregular astigmatism;

• corneal dystrophy;

• complications of transplanted cornea;

• post traumatic corneal scarring;

• keratoconus; and/or

• pterygium and/or corneal ectasia that cause visual impairment.

Limitations

Corneal topography will only be allowed for a pre-operative cataract patient if documentation supports that the patient has irregular astigmatism

Corneal topography is to be billed only when the diagnosis of monocular diplopia is thought to be caused by a corneal irregularity.

Corneal Topography is a covered service for the above indications when medically reasonable and necessary only if the results will assist in defining further treatment. It is not covered for routine follow-up testing.

Repeat testing is only indicated if a change of vision is reported in connection with one of the above listed conditions.

Services performed for screening purposes or in the absence of associated signs, symptoms, illness or injury as indicated above, will be denied as non-covered.

Corneal Topography will be non-covered if performed pre- or post-operatively in relation to a Medicare non- covered procedure, i.e., radial keratotomy.

Per CMS Pub 100-03, Chapter 1, Part 1, Section 80.7, Refractive keratoplasty is surgery to reshape the cornea of the eye to correct vision problems such as myopia (nearsightedness) and hyperopia (farsightedness). Refractive keratoplasty procedures include keratomileusis, in which the front of the cornea is removed, frozen, reshaped, and stitched back on the eye to correct either near or farsightedness; keratophakia, in which a reshaped donor cornea is inserted in the eye to correct farsightedness; and radial keratotomy, in which spoke-like slits are cut in the cornea to weaken and flatten the normally curved central portion to correct nearsightedness.

The correction of common refractive errors by eyeglasses, contact lenses or other prosthetic devices is specifically excluded from coverage. The use of radial keratotomy and/or keratoplasty (Refractive Surgeries) for the purpose of refractive error compensation is considered a substitute or alternative to eye glasses or contact lenses which are specifically excluded by §1862 (a)(7) of the Act (except in certain cases in connection with cataract surgery). In addition, many in the medical community consider such procedures cosmetic surgery which is excluded by

§§1862 (a)(10) of the Act. Therefore, radial keratotomy and keratoplasty (Refractive Surgeries) to treat refractive defects are not covered.

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 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.

999x Not Applicable

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 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

92025 COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT

ICD-9 Codes that Support Medical Necessity

367.21 * REGULAR ASTIGMATISM

367.22 * IRREGULAR ASTIGMATISM

368.2 DIPLOPIA

371.00 CORNEAL OPACITY UNSPECIFIED

371.23 BULLOUS KERATOPATHY

371.46 NODULAR DEGENERATION OF CORNEA

371.48 PERIPHERAL DEGENERATIONS OF CORNEA

371.52 OTHER ANTERIOR CORNEAL DYSTROPHIES

371.60 KERATOCONUS UNSPECIFIED

371.61 KERATOCONUS STABLE CONDITION

371.62 KERATOCONUS ACUTE HYDROPS

371.71 CORNEAL ECTASIA

372.40 PTERYGIUM UNSPECIFIED

372.41 PERIPHERAL PTERYGIUM STATIONARY

372.42 PERIPHERAL PTERYGIUM PROGRESSIVE

372.43 CENTRAL PTERYGIUM

372.44 DOUBLE PTERYGIUM

372.45 RECURRENT PTERYGIUM

372.52 PSEUDOPTERYGIUM

996.51 MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT V42.5* CORNEA REPLACED BY TRANSPLANT

V45.61* CATARACT EXTRACTION STATUS

V45.69* OTHER STATES FOLLOWING SURGERY OF EYE AND ADNEXA

*ICD-9-CM code 367.21 must be accompanied by diagnosis code V45.61 or V45.69

*ICD-9-CM code 367.22 must be accompanied by diagnosis code V45.61 or V45.69

*According to the ICD-9-CM book, diagnosis codes V42.5, V45.61 and V45.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation submitted by the ordering/referring physician must indicate the medical necessity for performing the procedure and the results derived from the corneal topography procedure. This information is usually found in the history and physical, office/progress notes and the computerized corneal topography imaging interpretation and report.

Appendices

Utilization Guidelines It is expected that these services would 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.

Sources of Information and Basis for Decision

American Academy of Ophthalmology. (2006). Preferred Practice Pattern for Cataract in the Adult Eye. Retrieved March 30, 2007 from www.aao.org website.

Fedor, . (2006). -Corneal Topography and Imaging. Available at http://www.emedicine.com/oph/topic711.htm Rasheed, K. (2005). Pellucid Marginal degeneration. Available at http://www.emedicine.com/OPH/topic551.htm.

Szczotka, L. (2003). Corneal topography and contact lenses. Ophthalmology Clinics of North America 16(3). W.B. Saunders Company

Verdler, D. (2005). Dystrophy, Map-dot-fingerprint. Available at http://www.emedicine.com/oph/topic95.htm.

Wang, L.; Koch, D. (2005). Corneal Topography and its Intergration into Refractive Surgery. Comprehensive Ophthalmology Update 6 (2) pp73-81.

Weissman, B. (2007). Keratoconus. Available at http://www.emedicine.com/oph/topic104.htm.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29122) replaces LCD L6161 as the policy in notice. This document (L29122) is effective on 02/02/2009.

Reason for Change