LCD/NCD Portal

L29238

 

OCULAR CORNEAL PACHYMETRY

 

03/22/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

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

o To determine the amount of endothelial trauma sustained during surgery.

o Assessment of the health of the cornea pre-operatively in Fuch’s dystrophy.

o Post ocular trauma.

o For the assessment of corneal thickness following diagnosis of increased intraocular pressure prior to the initiation of a treatment regimen for glaucoma.

o It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime.

• Medicare will consider ocular corneal pachymetry to be medically necessary and reasonable when performed only by providers of ophthalmology and optometry services or other providers who have specialized training and expertise in performing ocular corneal pachymetry.

o Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty.

o If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.

• Medicare will NOT pay for use of ocular corneal 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:

o Myopia. (nearsightedness).

o Hyperopia. (farsightedness).

• Effective for dates of service on or after 06/21/2006, Medicare will pay for ocular corneal pachymetry performed on patients who have been diagnosed and under treatment for glaucoma when there is documented worsening of glaucoma and the corneal thickness is unknown.

o The test must be integral to the medical management decision-making of the patient.

o Medicare will NOT pay for ocular corneal pachymetry when performed on patients who have been diagnosed and are under treatment for glaucoma that is stable and shows no evidence of progression/worsening of symptoms.

 

CPT/HCPCS Codes

 

 

76514 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS)

 

ICD-9 Codes that Support Medical Necessity

 

 

364.22 GLAUCOMATOCYCLITIC CRISES

364.77 RECESSION OF CHAMBER ANGLE OF EYE

365.00 PREGLAUCOMA UNSPECIFIED

365.01 OPEN ANGLE WITH BORDERLINE FINDINGS, LOW RISK

365.02 ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA

365.03 STEROID RESPONDERS BORDERLINE GLAUCOMA

365.04 OCULAR HYPERTENSION

365.05 OPEN ANGLE WITH BORDERLINE FINDINGS, HIGH RISK

365.06 PRIMARY ANGLE CLOSURE WITHOUT GLAUCOMA DAMAGE

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

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

365.21 INTERMITTENT ANGLE-CLOSURE GLAUCOMA

365.22 ACUTE ANGLE-CLOSURE GLAUCOMA

365.23 CHRONIC ANGLE-CLOSURE GLAUCOMA

365.24 RESIDUAL STAGE OF ANGLE-CLOSURE GLAUCOMA

365.31 CORTICOSTEROID-INDUCED GLAUCOMA GLAUCOMATOUS STAGE

365.32 CORTICOSTEROID-INDUCED GLAUCOMA RESIDUAL STAGE

365.41 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES

365.42 GLAUCOMA ASSOCIATED WITH ANOMALIES OF IRIS

365.43 GLAUCOMA ASSOCIATED WITH OTHER ANTERIOR SEGMENT ANOMALIES

365.44 GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.51 PHACOLYTIC GLAUCOMA

365.52 PSEUDOEXFOLIATION GLAUCOMA

365.59 GLAUCOMA ASSOCIATED WITH OTHER LENS DISORDERS

365.60 GLAUCOMA ASSOCIATED WITH UNSPECIFIED OCULAR DISORDER

365.61 GLAUCOMA ASSOCIATED WITH PUPILLARY BLOCK

365.62 GLAUCOMA ASSOCIATED WITH OCULAR INFLAMMATIONS

365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE

365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS

365.65 GLAUCOMA ASSOCIATED WITH OCULAR TRAUMA

365.70 GLAUCOMA STAGE, UNSPECIFIED

365.71 MILD STAGE GLAUCOMA

365.72 MODERATE STAGE GLAUCOMA

365.73 SEVERE STAGE GLAUCOMA

365.74 INDETERMINATE STAGE GLAUCOMA

365.81 HYPERSECRETION GLAUCOMA

365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE

365.83 AQUEOUS MISDIRECTION

365.89 OTHER SPECIFIED GLAUCOMA

365.9 UNSPECIFIED GLAUCOMA

371.23 BULLOUS KERATOPATHY

371.57 ENDOTHELIAL CORNEAL DYSTROPHY

371.58 OTHER POSTERIOR CORNEAL DYSTROPHIES

996.51 MECHANICAL COMPLICATION OF PROSTHETIC CORNEAL GRAFT

 

 

Documentation Requirements

• Medical record documentation maintained by the ordering/referring physician must indicate the medical necessity for performing the test and the test results.

o In addition, if the service exceeds the frequency parameter listed in this policy, documentation of medical necessity must be submitted.

o 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 must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies.

o The physician must state the clinical indication/medical necessity for the study in his order for the test.

• Documentation should contain a history and physical which supports the diagnosis for which this service is being rendered.

• Appendices

 

Utilization Guidelines

• It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime.

• It is expected that services performed for worsening of glaucoma will be performed once in a lifetime.

 

Treatment Logic

• Ocular Corneal Pachymetry is the ultrasonic measurement of corneal thickness.

• 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.

Sources of Information and Basis for Decision

 

Aihara, M. et al. (2003) Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. American Journal of Ophthalmology: 136, 805-813.

 

Albert, D.M., & Jakobiac, F.A. (2000). Principles and Practice of Ophthalmology (2nd ed.) W.B. Saunders. This reference was used to gain textbook knowledge of the cornea.

 

Bohnke, M., Mojon D.S., Sobottka, A.C (2001) Central corneal thickness measurements in patients with normal tension glaucoma, primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. Br. J. Ophthalmology: 85, 792-795.

 

Brandt, J. (2004) Corneal thickness in glaucoma screening, diagnosis and management. Current Opinion in Ophthalmology: 15, 85-89.

 

Chen, P., Kim, J. (2004) Central corneal pachymetry and visual field progression in patients with open-angle glaucoma. Ophthalmology: 111, 2126-2132.

 

FCSO LCD 29238, Ocular Corneal Pachymetry, 03/22/2012. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Herndon, L.; Stinnet, S., &Weizer, J. (2004) Central corneal thickness as a risk factor for advanced glaucoma damage. Archives of Ophthalmology: 122, 17-21.Kass, Micheal A., et al (2002) The ocular hypertension treatment study: A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Archives of Ophthalmology: June 2002, Volume 120, 701-711. This reference provided data which supported that ocular hypertension may be the result of abnormal corneal thickness.

 

Nemuesure, B., Wu, S., Hennis, A., & Leske, C. M (2003) Corneal thickness and intraocular pressure in the Barbadoes eye studies. (2003). Archives of Ophthalmology: 121, 240-244. This reference provided information regarding subjects determined to have increased corneal thickness and its relationship to increased ocular pressure.

 

Shih, C., Trokel, S., Tsai, J., Zivin, J., (2004) Clinical significance of central corneal thickness in the management of glaucoma: Archives of Ophthalmology: 122, 1270-1275.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

 CMS LCD L29238 Ocular Corneal Pachymetry