Ophthalmology and Optometry Coding Alert

Question: Will Medicare reimburse for 92004 or 92014 with the diagnosis code 367.9?


Alabama Subscriber


Answer: In general, Medicare will not reimburse for services--such as comprehensive new or established patient eye exams (92004 or 92014)--linked to refractive error, which it sees as a cosmetic problem, rather than a medical problem. However, individual Part B carriers may look at ICD-9 code 367.9 (Unspecified disorder of refraction and accommodation) differently.

Cahaba, the Part B carrier for Alabama, has published a local coverage determination (LCD) for general ophthalmology services (92002-92014). The LCD lists 367.9 as a noncovered ICD-9 code for general ophthalmology services. They would reject a claim of 92004 or 92014 linked to 367.9. However, Noridian, the Part B carrier in Colorado, North Dakota, South Dakota and Wyoming, lists 367.9 as a diagnosis code that does support medical necessity for 92002-92014.

Best bet: Check your individual carrier’s policy. Most carriers make their coverage decisions available on their Web sites (for example, www.cahabagba.com). There is also a tool on the CMS Web site. Go online to www.cms.hhs.gov/mcd/search.asp?, and select “local coverage.” Pick your state or contractor and enter the code in the search box. You should find your local policy for general ophthalmologic services, if there is one. Check the list of ICD-9 codes that support medical necessity.