L29244-LCD

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Local Coverage Determination (LCD) for Optical Coherence Biometry (L29244)

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 L29244

LCD Title

Optical Coherence Biometry

Contractor's Determination Number 92136

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: Program Memorandum B-03-001 (Change Request 2530, dated 01/17/2003)

Program Memorandum AB-03-119 (Change Request 2853, dated 08/08/2003)

Program Memorandum 105 (Change Request 3128, dated 02/20/2004)

Indications and Limitations of Coverage and/or Medical Necessity

Optical Coherence Biometry (OCB) is a new ophthalmic diagnostic test to perform ophthalmic biometry and intraocular lens (IOL) calculation without ultrasound. The instrument utilized is a non-invasive, non-contact device that measures axial length, corneal curvature, and anterior chamber depth taking a series of measurements. All measurements are stored in a computer, as well as automatically transferred to the IOL calculation program, which allows the surgeon immediate and individualized computation of IOL implant options for his/her patient. The method takes about one minute per eye.

Medicare will consider the performance of OCB medically reasonable and necessary if performed preoperatively by the operating surgeon or his/her designee for the purpose of determining intraocular lens power in a patient undergoing cataract surgery. Generally, it is expected that the provider that is performing the cataract surgery will perform OCB.

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

92136 OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH INTRAOCULAR LENS POWER CALCULATION

ICD-9 Codes that Support Medical Necessity

366.00 - 366.04 opens in new

window NONSENILE CATARACT UNSPECIFIED - NUCLEAR NONSENILE CATARACT

366.10 SENILE CATARACT UNSPECIFIED

366.11 PSEUDOEXFOLIATION OF LENS CAPSULE

366.13 ANTERIOR SUBCAPSULAR POLAR SENILE CATARACT

366.14 POSTERIOR SUBCAPSULAR POLAR SENILE CATARACT

366.15 CORTICAL SENILE CATARACT

366.16 SENILE NUCLEAR SCLEROSIS

366.17 TOTAL OR MATURE CATARACT

366.18 HYPERMATURE CATARACT

366.19 OTHER AND COMBINED FORMS OF SENILE CATARACT

366.20 TRAUMATIC CATARACT UNSPECIFIED

366.22 TOTAL TRAUMATIC CATARACT

366.30 CATARACTA COMPLICATA UNSPECIFIED

366.32 CATARACT IN INFLAMMATORY OCULAR DISORDERS

366.33 CATARACT WITH OCULAR NEOVASCULARIZATION

366.34 CATARACT IN DEGENERATIVE OCULAR DISORDERS

366.41 - 366.46 opens in new window

379.31 - 379.34 DIABETIC CATARACT - CATARACT ASSOCIATED WITH RADIATION AND OTHER PHYSICAL INFLUENCES

APHAKIA - POSTERIOR DISLOCATION OF LENS

743.30 CONGENITAL CATARACT UNSPECIFIED

743.31 CONGENITAL CAPSULAR AND SUBCAPSULAR CATARACT

743.32 CONGENITAL CORTICAL AND ZONULAR CATARACT

743.33 CONGENITAL NUCLEAR CATARACT

743.34 CONGENITAL TOTAL AND SUBTOTAL CATARACT

743.35 CONGENITAL APHAKIA

996.53 MECHANICAL COMPLICATION OF PROSTHETIC OCULAR LENS PROSTHESIS

V43.1* LENS REPLACED BY OTHER MEANS

* According to the ICD-9-CM book, diagnosis code V43.1 is a secondary diagnosis code 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 N/A

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 maintained by the performing provider must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s record. This information is normally found in the office/progress notes and/or procedure report.

Documentation should support the criteria as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

Eleftheriadis, H. (2003). Scientific Report, IOL Master biometry: refractive results of 100 consecutive cases. British Journal of Ophthalmology, 87, 960-963.

Haigis, W., Lege, B., Miller, N., & Schneider, B. (2000). Comparison of immersion ultrasound biometry and partial coherence interferometry for intraocular lens calculation according to Haigis. Graefe’s Archives of Clinical Experience in Ophthalmology, 238, 765-773. This document was used in the evaluation of the differences between OCB and the A-scan.

Hill, W. E. (2003). IOL power calculation accuracy. How to avoid common errors. Cataract & Refractive Surgery Today. Retrieved from http://www.crstodayarchive.com/03_archive/1003/051.html on September 13, 2005.

Santodomingo-Rubio, J., Mallen, E.A.H., Gilmartin, B., and Wolffsohn, J.S. (2002). Clinical Science, A new non- contact optical device for ocular biometry. British Journal of Ophthalmology, 86, 458-462.

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 (L29244) replaces LCD L6045 as the policy in notice. This document (L29244) is effective on 02/02/2009.

Reason for Change