Coding & Reimbursement

Correction of Corneal Astigmatism

By Suzanne L. Corcoran, COE

Ophthalmologists have a variety of options available to them for the management of astigmatism, including eyeglasses, hard or soft contact lenses and a variety of surgical procedures. This column addresses the issues associated with surgical correction of corneal astigmatism (SCOCA).

Q. What options are available for the surgical correction of astigmatism?

A. There are many surgical options, including limbal relaxing incisions (LRI), corneal relaxing incisions (CRI), astigmatic keratotomy (AK) and LASIK procedures. New variations on these procedures are being presented frequently.

Q. Does Medicare cover surgery to correct corneal astigmatism?

A. Medicare rarely covers surgical correction of corneal astigmatism. Astigmatism may be either pre-existing or iatrogenic (e.g., induced by the effects of treatment, usually surgery). Medicare covers refractive surgery in the rare instances when it is performed to correct a surgical complication or trauma. Surgically induced astigmatism may be covered; treatment of pre-existing astigmatism is considered refractive surgery and is non-covered.

When the procedure is covered as iatrogenic, CPT contains two codes that identify it: 65772 (CRIs for correction of surgically induced astigmatism) and 65775 (Corneal wedge resection for correction of surgically induced astigmatism).

The mere existence of iatrogenic astigmatism does not automatically make astigmatic correction a covered service. Before all elective surgeries, patient lifestyle complaints, along with trial and failure of prior treatment, need to be well documented in the patient record. Examples of patient complaints include monocular diplopia interfering with driving and reading, or inability to wear contact lenses due to poor comfort. The clinical notes would include a discussion regarding a trial of eyeglasses, and possibly contact lenses, without success.

Very few Medicare contractors have addressed the issue of the amount of astigmatism in their policies. The Florida contractor indicates a 4 D change is required (policy now retired) and Noridian (policy now retired) requires a change of 2.5 D in astigmatic power. Other contractor policies leave it unstated or indicate that medical necessity will be determined on a case-by-case basis.

If your Medicare contractor does not have a specific policy, and where coverage is questionable, patients should be informed of the possibility of a denial and the likelihood they may be required to pay. Obtain the patient's signature on an Advance Beneficiary Notice.

Q. Why doesn't Medicare cover procedures to correct pre-existing astigmatism?

Procedures performed to reduce or eliminate the patient's dependence on eyeglasses are not covered. The Medicare National Coverage Determinations Manual (NCD) contains specific instructions about refractive surgery in NCD §80.7, which specifies that "…keratoplasty for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact lenses, which are specifically excluded… keratoplasty to treat refractive defects are not covered."

In most patients, corneal astigmatism is not surgically induced; therefore, correction of that astigmatism is considered elective refractive surgery. Because CPT does not include a code for this indication, use code 66999 (unlisted procedure, anterior segment of the eye). Refractive surgery is not a Medicare benefit. Patients should be made aware of their obligation to pay. Consider obtaining the patient's signature on a Notice of Exclusion from Medicare Benefits. A sample form is available on my Web site (see biography).

Q. What tests are required prior to surgery and are they covered by Medicare?

Surgeons commonly perform additional testing prior to surgery to assess the cornea and quantify the degree and position of the astigmatism. Tests may include refraction, corneal topography, contact lens fitting, aberrometry and corneal pachymetry.

Medicare does not cover refractions, but when appropriate, a charge may be made to the patient (CPT 92015). Medicare will reimburse claims for corneal pachymetry (CPT 76514) and corneal topography (CPT 92025) when the service is performed in conjunction with a covered surgical procedure and in the presence of a valid diagnosis. When performed in conjunction with a refractive procedure, the tests are not covered. OM