When we look at the array of diagnostic tests available to ophthalmologists, endothelial cell count (ECC) is often overlooked. But it can be a valuable tool when used appropriately. Read on for what you need to know for accurate coding.
Q. Does Medicare cover ECC performed with a specular microscope?
A. Yes, when medically necessary. Medicare has a national coverage determination policy (NCD 80.8) addressing reimbursement for ECC, also known as endothelial cell photography or specular microscopy.
Q. What is Medicare’s coverage policy?
A. ECC is a covered procedure under Medicare when reasonable and necessary for patients who meet one or more of the following criteria:
- Have slit lamp evidence of endothelial dystrophy (e.g., corneal guttata, H18.51)
- Have slit lamp evidence of corneal edema (H18.1-, H18.2-)
- Are about to undergo a secondary intraocular lens implantation (H27.0)
- Have had previous intraocular surgery and require cataract surgery (e.g., Z98.83-)
- Are about to undergo a surgical procedure associated with a higher risk to corneal endothelium, i.e., phacoemulsification or refractive surgery (subject to some limitations for excluded refractive procedures)
- Have evidence of posterior polymorphous dystrophy of the cornea (H18.58) or iridocorneal endothelial syndrome (H21.26-, H18.51)
- Are about to be fitted with extended wear contact lenses after intraocular surgery (H27.0-, Z96.1, Z98.83)
Some individual Medicare Administrative Contractors (MACs) have published other covered indications, including visual disturbance (R48.3, H53.8) and congenital aphakia (Q12.3). Check your local policies.
Q. What are the limitations on coverage?
A. Medical coverage policies require that ECC, as with all diagnostic tests, must have specific relevance to the individual patient and be utilized in the management of the patient’s condition. “Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.” (42 CFR §410.32, Medicare diagnostic test policy)
As stated in NCD 80.8, when the only visual problem is cataract, ECC is considered part of the pre-surgical eye exam and not separately billable. This test is also not covered if performed in the preoperative evaluation for refractive keratoplasty to correct common refractive errors, although then it would be charged to the patient as part of the refractive package.
Q. What documentation is required in the medical record to support claims for ECC?
A. A physician’s interpretation and report are required. A brief notation such as “abnormal” does not suffice. In addition to the images, the medical record should include:
- Order for the test with medical rationale
- Date of the test
- Reliability of the test (e.g., poor, due to corneal scarring)
- Test findings (e.g., number of cells/mm2 morphology)
- Comparison with prior tests (if applicable)
- A diagnosis (if possible)
- The impact on treatment and prognosis
- Physician’s signature
Q. What are the supervision requirements?
A. Under Medicare program standards, this test requires general supervision. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.
Q. How much does Medicare allow for this test?
A. CPT code 92286 (Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis) describes ECC. This is a bilateral service, so a single payment is made for both eyes. The 2018 national Medicare Physician Fee Schedule allowable is $39.24. Of this amount, $16.56 is assigned to the technical component and $22.68 is the value of the professional component (interpretation). The specific allowable for each geographic area is adjusted by local indices.
ECC is subject to Medicare’s Multiple Procedure Payment Reduction (MPPR). This reduces the allowable for the technical component of the lesser-valued test when more than one test is performed on the same day.
Q. Are there bundles pertinent to ECC?
A. According to Medicare’s National Correct Coding Initiative (NCCI), separate reimbursement is allowed for ECC when performed in conjunction with exams (except the technician exam, 99211) or other tests.
Q. How often may this test be repeated on a patient?
A. No published limitations for repeated testing currently exist. Medicare utilization data for 2016 shows that ECC was associated with 0.4% of all eye exams by optometrists and ophthalmologists. In general, diagnostic tests are reimbursed when medically indicated. Clear documentation of the reason for testing is always required. Most often, the justification is an indication of progression of a chronic disease.
Q. If coverage of ECC is unlikely or uncertain, how should we proceed?
A. Explain why ECC is necessary and that Medicare or other third-party payers will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
- An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
- For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes and are not permitted to use the Medicare ABN form.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN. OM