Ophthalmology and Optometry Coding Alert

Question: Is there a limited coverage diagnosis table for procedure code 65865?

Texas Subscriber

Answer: Code 65865 (severing adhesions of anterior segment of eye, incisional technique [with or without injection of air or liquid] [separate procedure], goniosynechiae), should be paid by Medicare and other payers based on the diagnosis submitted that supports the medical necessity for performing the procedure. Although there is not a national list of covered diagnosis codes for the procedure, most carriers do have what are called claim edits in their systems.

Claim edits associate diagnosis codes with procedure codes to assist with the claim processing procedure. If you submit a claim for a service and receive a denial based on medical necessity, most likely the diagnosis code you submitted was not in the claim edit. This does not mean Medicare is not responsible for paying for the service, but you will have to send the claim to review explaining why the service was medically necessary. If you repeatedly receive a denial for the service based on a specific diagnosis code, you can contact your state ophthalmological society to help you have the diagnosis code added to the claim edit system. Your state society will have a member serving as a TPR, or third-party representative, and they may also have a CAC, or carrier advisory committee, member. The TPR or CAC member can approach the carrier on your behalf and explain why the diagnosis edits or coverage list should be expanded.