Download PG0037 Corneal Pachymetry

POLICY . . . . . . . . PG-0037
EFFECTIVE . . . . . .09/15/04
LAST REVIEW . . . 10/08/13
MEDICAL POLICY
Corneal Pachymetry
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder
contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure
reporting and does not imply coverage and reimbursement.
DESCRIPTION
Corneal pachymetry is a non-invasive ultrasonic technique for measuring corneal thickness. It is primarily used to
assist with the diagnosis, assessment, and/or monitoring of corneal diseases and to assess suspected or
established glaucoma.
POLICY
Corneal pachymetry does not require prior authorization
Corneal pachymetry is covered when the test is integral to the medical management decision-making of the patient;
and
Corneal pachymetry is covered for the patient who has one of the following conditions:
 Corneal ectasias, e.g., keratoglobus, pellucid degeneration, and keratoconus
 Fuch’s endothelial dystrophy or bullous keratopathy
 Posterior polymorphous dystrophy
 Corneal rejection post-penetrating keratoplasty
 Corneal edema
 Elevated intraocular pressure in glaucoma suspect when corneal thickness is unknown
 Worsening of glaucoma when corneal thickness is unknown
 Enlarged cup-disc ratio is equal to or greater than 0.3
Corneal pachymetry is covered preoperatively for patients scheduled for corneal transplant.
Corneal pachymetry is covered postoperatively when the test is performed following corneal transplant.
Corneal pachymetry is not covered to evaluate refractive errors.
HMO, PPO, Individual Marketplace, Elite, Advantage
This is considered a covered service for all members.
This service cannot be submitted with modifier –50, as it represents a bilateral service within its CPT descriptor. It
will be denied if submitted with this modifier. If the procedure is only performed on a single side, the service should
be reported with modifier –52, and reimbursement will be allowed at 50% of the fee schedule.
Corneal pachymetry will be allowed once per lifetime for the evaluation of the patient who meets the indications of
coverage. The medical record should reflect the medical necessity for the performance of the pachymetry service,
as well as the results, medical management, indications and determinations.
CODING/BILLING INFORMATION
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria
that must be met. Payment for supplies may be included in payment for other services rendered.
CPT CODES
76514
Corneal pachymetry, unilateral or bilateral (determination of corneal thickness)
ICD-9-CM CODES
364.22
Glaucomatocyclitic crises
364.77
Recession of chamber angle of eye
365.00-365.9
371.00
371.10
371.11
371.12
371.13
371.14
371.15
371.16
371.20
371.21
371.22
371.23
371.50
371.57
371.58
371.60
371.61
371.62
Glaucoma
Corneal opacity, unspecified
Corneal deposit, unspecified
Anterior corneal pigmentations
Stromal corneal pigmentations
Posterior corneal pigmentations
Kayser-Fleischer ring
Other corneal deposits associated with metabolic disorders
Argentous corneal deposits
Corneal edema, unspecified
Idiopathic corneal edema
Secondary corneal edema
Bullous keratopathy
Hereditary corneal dystrophy, unspecified
Endothelial corneal dystrophy
Other posterior corneal dystrophies
Keratoconus, unspecified
Keratoconus, stable condition
Keratoconus, acute hydrops
371.70
Corneal deformity, unspecified
371.71
377.14
743.10-743.12
743.20-743.22
743.41-743.49
996.51
996.89
V45.61
V45.69
Corneal ectasia
Glaucomatous atrophy [cupping] of optic disc
Microphthalmos, unspecified – Microphthalmos associated with other anomalies of eye and adnexa
Buphthalmos, unspecified - Buphthalmos associated with other ocular anomalies
Congenital anomalies of corneal size and shape - Other congenital anomalies of anterior segment
Mechanical complication due to corneal graft
Complications of other specified transplanted organ
Cataract extraction status
Other states following surgery of eye and adnexa
ICD-10-CM CODES; EFFECTIVE 10/01/2015
H17.89
H17.9
H18.001
H18.002
H18.003
H18.009
H18.011
H18.012
H18.013
H18.019
H18.021
H18.022
H18.023
H18.029
H18.031
H18.032
H18.033
H18.039
H18.041
H18.042
H18.043
H18.049
H18.051
Other corneal scars and opacities
Unspecified corneal scar and opacity
Unspecified corneal deposit, right eye
Unspecified corneal deposit, left eye
Unspecified corneal deposit, bilateral
Unspecified corneal deposit, unspecified eye
Anterior corneal pigmentations, right eye
Anterior corneal pigmentations, left eye
Anterior corneal pigmentations, bilateral
Anterior corneal pigmentations, unspecified eye
Argentous corneal deposits, right eye
Argentous corneal deposits, left eye
Argentous corneal deposits, bilateral
Argentous corneal deposits, unspecified eye
Corneal deposits in metabolic disorders, right eye
Corneal deposits in metabolic disorders, left eye
Corneal deposits in metabolic disorders, bilateral
Corneal deposits in metabolic disorders, unspecified eye
Kayser-Fleischer ring, right eye
Kayser-Fleischer ring, left eye
Kayser-Fleischer ring, bilateral
Kayser-Fleischer ring, unspecified eye
Posterior corneal pigmentations, right eye
H18.052
H18.053
H18.059
H18.061
H18.062
H18.063
H18.069
H18.10
H18.11
H18.12
H18.13
H18.20
H18.221
H18.222
H18.223
H18.229
H18.231
H18.232
H18.233
H18.239
H18.50
H18.51
H18.59
H18.601
H18.602
H18.603
H18.609
H18.611
H18.612
H18.613
H18.619
H18.621
H18.622
H18.623
H18.629
H18.70
H18.711
H18.712
H18.713
H18.719
H18.791
H18.792
H18.793
H18.799
H21.551
H21.552
H21.553
H21.559
H40.001- H42
H47.231
H47.232
H47.233
H47.239
Q11.2
Posterior corneal pigmentations, left eye
Posterior corneal pigmentations, bilateral
Posterior corneal pigmentations, unspecified eye
Stromal corneal pigmentations, right eye
Stromal corneal pigmentations, left eye
Stromal corneal pigmentations, bilateral
Stromal corneal pigmentations, unspecified eye
Bullous keratopathy, unspecified eye
Bullous keratopathy, right eye
Bullous keratopathy, left eye
Bullous keratopathy, bilateral
Unspecified corneal edema
Idiopathic corneal edema, right eye
Idiopathic corneal edema, left eye
Idiopathic corneal edema, bilateral
Idiopathic corneal edema, unspecified eye
Secondary corneal edema, right eye
Secondary corneal edema, left eye
Secondary corneal edema, bilateral
Secondary corneal edema, unspecified eye
Unspecified hereditary corneal dystrophies
Endothelial corneal dystrophy
Other hereditary corneal dystrophies
Keratoconus, unspecified, right eye
Keratoconus, unspecified, left eye
Keratoconus, unspecified, bilateral
Keratoconus, unspecified, unspecified eye
Keratoconus, stable, right eye
Keratoconus, stable, left eye
Keratoconus, stable, bilateral
Keratoconus, stable, unspecified eye
Keratoconus, unstable, right eye
Keratoconus, unstable, left eye
Keratoconus, unstable, bilateral
Keratoconus, unstable, unspecified eye
Unspecified corneal deformity
Corneal ectasia, right eye
Corneal ectasia, left eye
Corneal ectasia, bilateral
Corneal ectasia, unspecified eye
Other corneal deformities, right eye
Other corneal deformities, left eye
Other corneal deformities, bilateral
Other corneal deformities, unspecified eye
Recession of chamber angle, right eye
Recession of chamber angle, left eye
Recession of chamber angle, bilateral
Recession of chamber angle, unspecified eye
Glaucoma
Glaucomatous optic atrophy, right eye
Glaucomatous optic atrophy, left eye
Glaucomatous optic atrophy, bilateral
Glaucomatous optic atrophy, unspecified eye
Microphthalmos
Q13.0
Q13.1
Q13.2
Q13.3
Q13.4
Q13.5
Q13.81
Q13.89
Q13.9
Q15.0
T85.318A
T85.318D
T85.318S
T85.328A
T85.328D
T85.328S
T85.398A
T85.398D
T85.398S
T86.830
T86.831
T86.832
T86.838
T86.839
T86.840
T86.841
T86.890
T86.891
T86.892
T86.898
T86.899
Z98.41
Z98.42
Z98.49
Z98.83
Coloboma of iris
Absence of iris
Other congenital malformations of iris
Congenital corneal opacity
Other congenital corneal malformations
Blue sclera
Rieger's anomaly
Other congenital malformations of anterior segment of eye
Congenital malformation of anterior segment of eye, unspecified
Congenital glaucoma
Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter
Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, subsequent encounter
Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, sequela
Displacement of other ocular prosthetic devices, implants and grafts, initial encounter
Displacement of other ocular prosthetic devices, implants and grafts, subsequent encounter
Displacement of other ocular prosthetic devices, implants and grafts, sequela
Other mechanical complication of other ocular prosthetic devices, implants and grafts, initial encounter
Other mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
Other mechanical complication of other ocular prosthetic devices, implants and grafts, sequela
Bone graft rejection
Bone graft failure
Bone graft infection
Other complications of bone graft
Unspecified complication of bone graft
Corneal transplant rejection
Corneal transplant failure
Other transplanted tissue rejection
Other transplanted tissue failure
Other transplanted tissue infection
Other complications of other transplanted tissue
Unspecified complication of other transplanted tissue
Cataract extraction status, right eye
Cataract extraction status, left eye
Cataract extraction status, unspecified eye
Filtering (vitreous) bleb after glaucoma surgery status
REVISION HISTORY EXPLANATION
01/01/06: No changes
08/01/07: Removed diagnosis editing
08/01/08: Updated references
08/15/09: No changes
01/01/11: No changes
10/08/13: Changes made per Medicare guidelines. Deleted codes 364.53, 366.11, & 996.80. Added codes 364.22,
371.00-371.16, 371.70, 377.14, 743.10-743.12, 743.20-743.22, 743.41-743.49, 996.89, V45.61, & V45.69. ICD-10
Codes added from ICD-9 conversion. Policy reviewed and updated to reflect most current clinical evidence.
Approved by Medical Policy Steering Committee as revised.
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services
Ohio Department of Medicaid http://jfs.ohio.gov/
American Medical Association, Current Procedural Terminology (CPT ) and associated publications and services
Industry Standard Review
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