Coding & Reimbursement

Answers on Endothelial Cell Photography

By Suzanne L. Corcoran, COE

While endothelial cell photography, a diagnostic test, has been valuable to ophthalmologists for many years, there continues to be some confusion surrounding it. Specifically, questions about Medicare rules and reimbursement persist; I will attempt to clear up the confusion.

Q. Does Medicare cover endothelial cell count performed with a specular microscope?

A. Yes. There is a national coverage determination policy (NCD 80.8) addressing reimbursement for endothelial cell count, also known as endothelial cell photography or specular microscopy. It is considered 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) (371.57)
• Have slit lamp evidence of corneal edema (371.20-371.24)
• Are about to undergo a secondary intraocular lens implantation (379.31)
• Have had previous intraocular surgery and require cataract surgery (V45.69)
• 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 (371.58) or iridocorneal-endothelium syndrome (364.51, 371.57)
• Will be fitted with extended-wear contact lenses after intraocular surgery (379.31, V43.1, V45.69).

However, when the only visual problem is cataracts, endothelial cell photography is considered part of the presurgical eye exam provided prior to the cataract surgery, and is not separately billable. This test is not covered if performed in the preoperative evaluation for refractive keratoplasty to correct common refractive errors.

Under Medicare's National Correct Coding Initiative (NCCI), this test is not bundled or mutually exclusive with either exams or other diagnostic tests. It is billable on the same day subject to the limitations described above.

Q. What are the documentation requirements?

A. In addition to the photos of the endothelium or proof that digital images exist, the chart should contain:

• an order for the test with medical rationale
• the date of the test
• the reliability of the test (e.g., poor due to corneal scarring)
• the test findings (e.g., number of cells/mm²)
• a diagnosis (if possible)
• the impact on treatment and prognosis
• the signature of the physician.

A form suitable for documenting the interpretation of this test is available on Corcoran's Web site (see biography).

Q. Is the physician's presence required while the test is performed?

A. Under Medicare program standards, this test needs only 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. What is Medicare's allowed amount for this test?

A. Use CPT code 92286 to describe endothelial cell photography. This is a "bilateral" service, so a single payment is made for both eyes. The 2008 national Medicare fee schedule allowable is $121.12. Of this amount, $88.74 is assigned to the technical component and $32.37 is the value of the professional component.

The specific allowable for each geographic area is determined by adjusting the national rate by the geographical practice cost indices.

Q. How frequently may this test be performed?

A. There are no published limitations for repeated testing. In general, this and all diagnostic tests are reimbursed "when medically indicated." Clear documentation of the reason for testing is always required.

Q. May we ever bill the patient directly for this test?

A. Yes. Sometimes a physician may feel that this test is merited for reasons that do not comport with Medicare's policy. In a situation where Medicare might not cover the test, an Advance Beneficiary Notice should be signed by the patient prior to testing. Submit your claim as 92286-GA. You may collect your fee from the patient at the time of service or wait for a Medicare denial. OM