L29241-LCD

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Local Coverage Determination (LCD) for Ophthalmological Diagnostic Services (L29241)

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 L29241

LCD Title

Ophthalmological Diagnostic Services

Contractor's Determination Number 92018

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

For services performed on or after 03/27/2012 Revision Ending Date

CMS National Coverage Policy

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Sections 80.6 and 80.8

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 90

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

Diagnostic ophthalmological services (92018-92499) rendered by a physician are covered services when medically necessary and reasonable for the patient's condition. Routine eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lens(es); eye refractions are noncovered.

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

92284 DARK ADAPTATION EXAMINATION WITH INTERPRETATION AND REPORT

92286 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH SPECULAR ENDOTHELIAL MICROSCOPY AND CELL COUNT

92287 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH FLUORESCEIN ANGIOGRAPHY

ICD-9 Codes that Support Medical Necessity

Dark Adaptation Examination (CPT Code 92284):

264.5 VITAMIN A DEFICIENCY WITH NIGHT BLINDNESS

362.74 PIGMENTARY RETINAL DYSTROPHY

365.20 PRIMARY ANGLE-CLOSURE GLAUCOMA UNSPECIFIED

368.60 NIGHT BLINDNESS UNSPECIFIED Endothelial Cell Photography (CPT Code 92286):

371.20 CORNEAL EDEMA UNSPECIFIED

371.21 IDIOPATHIC CORNEAL EDEMA

371.22 SECONDARY CORNEAL EDEMA

371.23 BULLOUS KERATOPATHY

371.57 ENDOTHELIAL CORNEAL DYSTROPHY

371.58 OTHER POSTERIOR CORNEAL DYSTROPHIES

379.31 APHAKIA

743.35 CONGENITAL APHAKIA

V43.1 LENS REPLACED BY OTHER MEANS

Special Anterior Segment Photography (CPT Code 92287):

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

250.50 - 250.53 opens DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT

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STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I

[JUVENILE TYPE], UNCONTROLLED

364.00 - 364.89 ACUTE AND SUBACUTE IRIDOCYCLITIS UNSPECIFIED - OTHER DISORDERS OF IRIS AND CILIARY BODY

365.41 - 365.44 GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES - GLAUCOMA ASSOCIATED WITH SYSTEMIC SYNDROMES

365.52 PSEUDOEXFOLIATION GLAUCOMA

365.63 GLAUCOMA ASSOCIATED WITH VASCULAR DISORDERS OF EYE

365.64 GLAUCOMA ASSOCIATED WITH TUMORS OR CYSTS

365.82 GLAUCOMA WITH INCREASED EPISCLERAL VENOUS PRESSURE 743.00 - 743.06 opens

in new window CLINICAL ANOPHTHALMOS UNSPECIFIED - CRYPTOPHTHALMOS

743.10 - 743.12 MICROPHTHALMOS UNSPECIFIED - MICROPHTHALMOS ASSOCIATED WITH OTHER ANOMALIES OF EYE AND ADNEXA

743.20 - 743.22 BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES

743.30 - 743.39 CONGENITAL CATARACT UNSPECIFIED - OTHER CONGENITAL CATARACT AND LENS ANOMALIES

743.41 - 743.48 CONGENITAL ANOMALIES OF CORNEAL SIZE AND SHAPE - MULTIPLE AND COMBINED CONGENITAL ANOMALIES OF ANTERIOR SEGMENT

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

• Office Notes supplying documentation of complaint or symptomatology for visual disturbances and the affect on activities of daily living

• Diagnostic test results

The provider has a responsibility to maintain a record for postpayment audit.

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

N/A 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 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2012 Original Effective Date:03/27/2012

LCR B2012-039

April 2012 Connection

Explanation of revision: The Medicare Physician Fee Schedule Database (MPFSDB) status indicator for CPT code 92015 is an “N” (Non-covered Service) therefore this code has been removed from the LCD. The Contractor’s Determination Number was changed from 92015 to 92018. Under the “Indications and Limitations of Coverage and/or Medical Necessity” section the range of CPT codes (92015-92499) was changed to (92018-92499). In addition, the “CMS National Coverage Policy” section was updated to include CMS Manual System, Pub 100-08, Medicare Program Integrity, Chapter 13, Section 13.1.3.The effective date of this revision is based on process date.

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 (L29241) replaces LCD L6023 as the policy in notice. This document (L29241) is effective on 02/02/2009.

Reason for Change Narrative Change