Ophthalmology and Optometry Coding Alert

Question: How should we bill for corneal topography? Our ophthalmologist says there must be a code other than the unlisted code.

Pennsylvania Subscriber

Answer: Your ophthalmologist has the right instinct. There should be a code for corneal topography. The American Academy of Ophthalmologys (AAO) committee, formally called the DPTR (diagnostic, procedural, terminology and reimbursement), tried on several occasions to obtain a code for corneal topography, but was unsuccessful. Since they were unable to obtain a specific code, they pursued reimbursement of the service through the corneal surgical codes. The DPTR committee presented the cost and statistical data in the last refinement period for the physician work portion of the corneal transplant surgery codes and was able to obtain increased values to represent the cost of performing corneal topography in relation to corneal transplant surgery.

In theory, due to the increased values, Medicare carriers should not be reimbursing separately for corneal topography in conjunction with these surgical procedures. Fortunately, the carriers do process payment for the service when billed with 92499 (unlisted ophthalmological service or procedure) because it is a medically necessary service in more instances than just corneal transplants. Most carriers have a local medical review policy (LMRP) for the service. When providing the service, be sure your medical record contains a copy of the test.

Although Medicare carriers will pay for corneal topography when you meet the requirements of their LMRP, some private payers have trouble recognizing unlisted codes. If a payer doesnt pay on corneal topography, it is probably because it does not know enough about the service. Contact the payer to find out exactly why it considers corneal topography a noncovered service. Is it denying for lack of medical necessity? If so, your medical record documentation should substantiate the medical necessity along with the diagnosis code that is submitted with your claim.

Does the payer require a written description of what the service is, why it is being performed (medical necessity) for this patient, and/or copies of the topographical printout? Offer to share the criteria your local Medicare carrier uses to determine the medical necessity for this service so that it can use the same or similar criteria. If all else fails, get one of your physicians on the phone with the payers medical director to have a medical discussion regarding the medical necessity. Medical necessity coverage policies are always set or revised by the medical director.

If these are contractual payers, you should check your contract for noncovered services. Make sure that if the payer considers the service noncovered, you will still be allowed to seek payment from the patient. Except in the case of contractual payers with whom you have an agreement to write off disallowed charges, until you find the reason for the denial, having the patient sign a waiver of liability is your best way to assure you are paid. A waiver, also referred to as an advance beneficiary notification (ABN) in the Medicare program, allows you to bill and collect the charges directly from the patient. The notice must specifically state that you believe the payer will not cover the service and the reason why you believe this. There is a patient statement that indicates they have read the waiver, it has been explained to them, and they have agreed to have the service performed on the condition that they are agreeing to pay for it themselves.

Note: It is not permissable to code corneal topography as an office visit. Doing so would be misrepresenting the service provided, which is one of the most common types of billing fraud the Office of the Inspector General has identified.