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Billing and Coding: Ophthalmological Diagnostic Services (A57463)

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Billing and Coding: Ophthalmological Diagnostic Services (A57463) Local Coverage Article: Billing and Coding: Ophthalmological Diagnostic Services (A57463) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information CONTRACTOR NAME CONTRACT TYPE CONTRACT NUMBER JURISDICTION STATE(S) First Coast Service Options, Inc. A and B MAC 09102 - MAC B J - N Florida First Coast Service Options, Inc. A and B MAC 09202 - MAC B J - N Puerto Rico First Coast Service Options, Inc. A and B MAC 09302 - MAC B J - N Virgin Islands Article Information General Information Article ID Original Effective Date A57463 10/03/2018 Article Title Revision Effective Date Billing and Coding: Ophthalmological Diagnostic N/A Services Revision Ending Date Article Type N/A Billing and Coding Retirement Date AMA CPT / ADA CDT / AHA NUBC Copyright N/A Statement CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Current Dental Terminology © 2018 American Dental Association. All rights reserved. Copyright © 2019, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity Created on 11/11/2019. Page 1 of 13 wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected]. CMS National Coverage Policy N/A Article Guidance Article Text: This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33925 Ophthalmological Diagnostic Services provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to the LCD for reasonable and necessary requirements and limitations. The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD. Coding Guidelines Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements 1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted Created on 11/11/2019. Page 2 of 13 CPT/HCPCS code must describe the service performed. 4. Office notes supplying documentation of complaint or symptomatology for visual disturbances and the effect on activities of daily living. 5. Diagnostic test results. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Compliance with the provisions in LCD L33925, Ophthalmological Diagnostic Services may be monitored and addressed through post payment data analysis and subsequent medical review audits. Coding Information CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: CODE DESCRIPTION 92284 DARK ADAPTATION EXAMINATION WITH INTERPRETATION AND REPORT Group 2 Paragraph: N/A Group 2 Codes: CODE DESCRIPTION 92286 ANTERIOR SEGMENT IMAGING WITH INTERPRETATION AND REPORT; WITH SPECULAR MICROSCOPY AND ENDOTHELIAL CELL ANALYSIS Group 3 Paragraph: N/A Group 3 Codes: CODE DESCRIPTION 92287 ANTERIOR SEGMENT IMAGING WITH INTERPRETATION AND REPORT; WITH FLUORESCEIN ANGIOGRAPHY CPT/HCPCS Modifiers N/A Created on 11/11/2019. Page 3 of 13 ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The following ICD-10-CM codes support medical necessity and provide limited coverage for CPT code: 92284 It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. Group 1 Codes: ICD-10 CODE DESCRIPTION E50.5 Vitamin A deficiency with night blindness H35.50 Unspecified hereditary retinal dystrophy H35.52 Pigmentary retinal dystrophy H35.53 Other dystrophies primarily involving the sensory retina H35.54 Dystrophies primarily involving the retinal pigment epithelium H40.20X0 Unspecified primary angle-closure glaucoma, stage unspecified H40.20X1 Unspecified primary angle-closure glaucoma, mild stage H40.20X2 Unspecified primary angle-closure glaucoma, moderate stage H40.20X3 Unspecified primary angle-closure glaucoma, severe stage H40.20X4 Unspecified primary angle-closure glaucoma, indeterminate stage H53.60 Unspecified night blindness H53.61 Abnormal dark adaptation curve H53.63 Congenital night blindness H53.69 Other night blindness Group 2 Paragraph: The following ICD-10-CM codes support medical necessity and provide limited coverage for CPT code: 92286 It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. Group 2 Codes: ICD-10 CODE DESCRIPTION H18.10 Bullous keratopathy, unspecified eye H18.11 Bullous keratopathy, right eye H18.12 Bullous keratopathy, left eye H18.13 Bullous keratopathy, bilateral Created on 11/11/2019. Page 4 of 13 ICD-10 CODE DESCRIPTION H18.20 Unspecified corneal edema H18.221 Idiopathic corneal edema, right eye H18.222 Idiopathic corneal edema, left eye H18.223 Idiopathic corneal edema, bilateral H18.229 Idiopathic corneal edema, unspecified eye H18.231 Secondary corneal edema, right eye H18.232 Secondary corneal edema, left eye H18.233 Secondary corneal edema, bilateral H18.239 Secondary corneal edema, unspecified eye H18.51 Endothelial corneal dystrophy H18.59 Other hereditary corneal dystrophies H27.00 Aphakia, unspecified eye H27.01 Aphakia, right eye H27.02 Aphakia, left eye H27.03 Aphakia, bilateral Q12.3 Congenital aphakia Z96.1 Presence of intraocular lens Group 3 Paragraph: The following ICD-10-CM codes support medical necessity and provide limited coverage for CPT code: 92287 It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. Group 3 Codes: ICD-10 CODE DESCRIPTION A18.54 Tuberculous iridocyclitis C69.40 Malignant neoplasm of unspecified ciliary body C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication H20.00 Unspecified acute and subacute iridocyclitis Created on 11/11/2019. Page 5 of 13 ICD-10 CODE DESCRIPTION H20.011 Primary iridocyclitis, right eye H20.012 Primary iridocyclitis, left eye H20.013 Primary iridocyclitis, bilateral H20.019 Primary iridocyclitis, unspecified eye H20.021 Recurrent acute iridocyclitis, right eye H20.022 Recurrent acute iridocyclitis, left eye H20.023 Recurrent acute iridocyclitis, bilateral H20.029 Recurrent acute iridocyclitis, unspecified eye H20.031 Secondary infectious iridocyclitis, right eye H20.032 Secondary infectious iridocyclitis, left eye H20.033 Secondary infectious iridocyclitis, bilateral H20.039 Secondary infectious iridocyclitis, unspecified eye H20.041 Secondary noninfectious iridocyclitis, right eye H20.042 Secondary noninfectious iridocyclitis, left eye H20.043 Secondary noninfectious iridocyclitis, bilateral H20.049 Secondary noninfectious iridocyclitis, unspecified eye H20.051 Hypopyon, right eye H20.052 Hypopyon, left eye H20.053 Hypopyon, bilateral H20.059 Hypopyon, unspecified eye H20.10 Chronic iridocyclitis, unspecified eye H20.11 Chronic iridocyclitis, right eye H20.12 Chronic iridocyclitis, left eye H20.13 Chronic iridocyclitis, bilateral H20.20 Lens-induced iridocyclitis, unspecified eye H20.21
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