coding & reimbursement
Coding Corneal Pachymetry
New uses and a new CPT code warrant a fresh look at the rules.

As you know, pachymetry is a measurement of the thickness of the cornea -- usually the central cornea, although there are diseases that warrant a pachymetry grid across a wide area. Pachymetry is primarily used when a diseased cornea is edematous or ectatic, or prior to LASIK to help plan the photoablation.

More recently, pachymetry has become useful in glaucoma detection. The Ocular Hypertension Treatment Study revealed that applanation tonometry of an unusually thin cornea results in a reading lower than the actual IOP because of reduced corneal resistance to indentation. Similarly, thick corneas yield false high readings. As a result, pachymetry is being used more often by physicians treating glaucoma, so that this factor is taken into account.

Q: Is there a CPT code for corneal pachymetry? Effective January 1, 2004, a regular CPT code has been assigned: 76514, Ophthalmic ultrasound, echography, diagnostic; corneal pachymetry, unilateral or bilateral. Interestingly, the new CPT code can only be used to report an ultrasound procedure. A number of devices currently on the market measure corneal thickness optically; pachymetry using these devices should be billed using 92499, Unlisted ophthalmological service or procedure.

When a new code is assigned, most payers, including Medicare, accept claims using the old code during a brief grace period -- usually January and February. (Prior to 2004, CPT Category III code 0025T, defined as determination of corneal thickness [e.g., pachymetry] with interpretation and report, bilateral, was the correct code to use.) By the time you read this, you'll need to bill using the new 2004 code.

Q: Does insurance always cover corneal pachymetry? Currently, Medicare has no national coverage policy for this service. However, many Medicare carriers have published local policies; most of these state that for glaucoma or glaucoma suspect, corneal pachymetry is only covered once in a patient's lifetime. Also, many policies cover pachymetry for glaucoma suspect only -- not for patients already diagnosed with glaucoma. Check your local carrier policies to be sure.

The 2004 national Medicare fee schedule allowable for 76514 is $11.59, although this amount is adjusted in each area by local indices. (The American Academy of Ophthalmology has stated that it is planning to appeal this level of reimbursement because the CPT language describes the procedure as being either unilateral or bilateral, which means it can't be billed per eye.) In the special case of optical pachymetry (92499), no Medicare fee schedule amount has been defined; each claim will be adjudicated on an individual basis. Pay-ment amounts may vary.

Private insurance coverage for corneal pachymetry also varies. Many payers cover it, but there are wide variations in the amount of reimbursement. A few payers don't cover it in connection with glaucoma -- at least so far -- and some bundle the test with an eye exam. You'll need to check with individual payers for coverage guidelines.

Q: If insurance doesn't cover the test, can I charge the patient? Usually you can, although you'll need to check with your private payers to determine their payment policies. For Medicare patients, explain why the test is necessary and that Medicare will probably deny the claim. Ask the patient to assume financial responsibility for the charge, and get the patient's signature on an Advance Beneficiary Notice (ABN). Use modifier -GA when you submit your claim.

You can collect your fee from the patient at the time of service, or wait for a Medicare denial. However, if both the patient and Medicare pay, be sure to refund the patient promptly.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.