Ophthalmology and Optometry Coding Alert

Question:  I am billing pachymetry (76514, 1 unit) with a diagnosis code of 365.04 (Ocular hypertension). However, Medicare is denying my claim saying, "Claim lacks information which is needed for adjudication. Additional information is supplied using the remittance advice remarks codes whenever appropriate." How can I correct this problem?

California Subscriber

Answer: Make sure you have the referring doctor’s name ("Name of Referring Physician or Other Source") and 17a ("I.D. Number of Referring Physician") of your CMS form — even if you yourself are the referring doctor. Omitting this information will prompt the denial message you receive.

Key: Medicare requires this information for diagnostic radiology services such as corneal pachymetry (76514, Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) as well as diagnostic laboratory services, portable x-ray services, consultative services, and durable medical equipment.

If, as is often the case, you are both the ordering and the performing physician, the Medicare Claims Processing Manual directs that "the performing physician’s name and NPI appear in items 17 and 17a" (Chapter 26, Section 10.4).

Caution: Medicare will usually reimburse for corneal pachymetry only once in the patient’s lifetime. If the patient has had the procedure before, that might also trigger denials, unless the new test is proven medically necessary.