Coding & Reimbursement

Wavefront Aberrometry and Medicare

By Suzanne L. Corcoran, COE

Determination of the refractive state of the eye is the most common ophthalmic ancillary diagnostic test performed in-office in conjunction with an eye exam. While there are numerous ways to measure refractive error, subjective refraction is the customary method. The result describes the amount of lower-order aberrations in the eye, including defocus (sphere), cylinder and tilt (prism).

This method is adequate in most cases, but some patients still complain of poor vision, which manifests as halos or glare even though their visual acuity is nominally 20/20. In ophthalmologists' quest to fully appreciate and understand the problems of these patients and to find a way to ameliorate them, it is useful to consider higher-order aberrations as well (e.g., spherical aberration, coma, trefoil, etc.). To do so, eyecare providers employ wavefront aberrometry, which is both objective and more thorough than the traditional subjective refraction.

Q. What CPT code best describes wavefront aberrometry?

A. If you search CPT for the term "wavefront aberrometry," you will not find it, but by understanding the test and how it works, we can avoid selecting a miscellaneous procedure code that usually results in billing headaches. We are instructed in CPT that "unlisted procedure codes should not be coded unless the coder has reviewed the CPT coding system carefully to ensure that a more specific code is not available." In this case, we should choose CPT 92015, since it is defined as determination of the refractive state of the eye; wavefront aberrometry is one way to do it.

Q. Does Medicare reimburse practices for wavefront aberrometry?

A. Medicare does not cover refractions for any reason, so we have every expectation that they will not cover wavefront aberrometry either. The Medicare Benefit Policy Manual (MBPM) Chapter 16 §90 states: "Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever purpose performed … are not covered … Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optom etrist and without regard to the reason for performance of the refraction, are excluded from coverage."

Q. Must we get an Advance Beneficiary Notice of Noncoverage (ABN) signed in order to collect from the patient?

A. No. As noted above, the relevant regulation specifically states that refractions are not covered by Medicare. You do not need an ABN for items or services that are statutorily (that is, by law) non-covered by Medicare. At your discretion you may choose to notify beneficiaries that these services are never covered, using the Advance Beneficiary Notice of Noncoverage (CMS-R-131) or a Notice of Ex clusion from Medicare Benefits (Form CMS-20007).

Use of these forms is optional, although many practices find it helpful to give the patient something in writing about refractions to avoid confusion. You can even make up your own form for this purpose if you wish. Sample forms are available at no charge on Corcoran's Web site at http://www.corcoranccg.com/Browse.aspx/388/Forms-(Free).

Charges for non-covered services such as refractions may be collected at the time of service. We strongly encourage practices to do so. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.