Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Corneal Pachymetry Using Ultrasound

Policy #:07.13.07j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Corneal pachymetry using ultrasound is considered medically necessary and, therefore, covered when it is performed as part of medical management for any of the following:
  • Assessing disease progression in corneas with endothelial cell dysfunction (e.g., Fuchs' endothelial dystrophy, posterior polymorphous dystrophy, endotheliitis, corneal trauma)
  • Assessing corneal edema
  • Assessing the health of corneal transplants
  • Aiding in the early diagnosis and/or treatment of corneal transplant rejection
  • Assessing the response of corneal transplant rejection to treatment
  • Assisting in the selection of the appropriate cataract surgical technique for individuals with prior intraocular surgery or established corneal diseases
  • Assessing the risk of corneal decompensation before and after cataract surgery in corneas with known endothelial disease
  • Assisting in the diagnosis of corneal thinning disorders (e.g., keratoconus, keratoglobus, keratotorus, posterior keratoconus, pellucid marginal degeneration)
  • Assessing corneal ectasia (e.g., keratoconus, pellucid marginal degeneration) or progressive corneal ectasia following keratorefractive surgery
  • Determining the influence of corneal thickness on intraocular pressure (IOP) measurements in individuals with suspected or established glaucoma
    • Performed once per lifetime

NOT MEDICALLY NECESSARY

Corneal pachymetry using ultrasound is considered not medically necessary and, therefore, not covered when it is performed for any of the following:
  • As part of an evaluation for refractive surgery
  • To evaluate refractive errors
  • As part of a screening process only (e.g., no evidence exists to suspect a diagnosis of glaucoma)
  • As a routine preoperative evaluation for cataract surgery, unless there is known endothelial disease
  • As a routine postoperative evaluation for any procedure other than a corneal transplant
  • Repeat testing on individuals with suspected or established glaucoma
  • For all other diagnoses or conditions that do not meet the medical necessity criteria listed above

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Corneal pachymetry using ultrasound should only be used if it will impact decisions regarding the medical management of the individual.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, corneal pachymetry using ultrasound is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

BILLING GUIDELINES

Corneal pachymetry using ultrasound should be reported only once when using CPT code 76514. Corneal pachymetry is considered a bilateral procedure. Modifier 50 should not be used when reporting corneal pachymetry using ultrasound.

Corneal pachymetry using ultrasound has both professional and technical components. When claiming only one of these components, append the appropriate modifier for the service performed (Modifier 26 or Modifier TC).

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Corneal pachymetry using ultrasound is a specialized, noninvasive, ophthalmologic procedure that uses a pachymeter to measure corneal thickness. Measurements of central corneal thickness are performed by applying a topical anesthetic to the eye and placing an ultrasound probe on the central cornea where ultrasonic wave energy is passed into the eye.

Corneal pachymetry using ultrasound is primarily used to assist with the diagnosis, assessment, and/or monitoring of corneal diseases and to assess suspected or established glaucoma. For example, corneal pachymetry using ultrasound is used to assist with the diagnosis of corneal thinning disorders (e.g., keratoconus, keratoglobus, keratotorus, posterior keratoconus, pellucid marginal degeneration). Corneal pachymetry using ultrasound is also included in the assessment and/or monitoring of disease progression of many conditions or injury affecting the cornea such as Fuchs' endothelial dystrophy, posterior polymorphous dystrophy, corneal edema, endothelial disease from any etiology, bullous keratopathy, corneal ectasia, and corneal trauma.

Corneal pachymetry using ultrasound is an important component of the assessment and management of intraocular pressure and glaucoma. Corneal thickness is important because it can mask an accurate reading of intraocular pressure in glaucoma. Actual intraocular pressure may be underestimated in individuals with thinner central corneal thickness or overestimated in individuals with thicker central corneal thickness. Because intraocular pressure is reportedly the most important and only variable risk factor for glaucoma progression, knowledge of the central corneal thickness is important in managing individuals with either suspected or established glaucoma. Repeat measurements of central corneal thickness for suspect or established glaucoma is not indicated unless the individual has corneal disease or has had surgery affecting corneal thickness. Corneal pachymetry for suspected or established glaucoma only needs to be performed once to obtain baseline glaucoma risk information.

In addition to assisting with the diagnosis, assessment, and/or the monitoring of corneal diseases and assessing suspected or established glaucoma, corneal pachymetry using ultrasound is valuable in the selection of appropriate surgical techniques and assessment of the individual's risk and response to certain ophthalmologic surgical procedures (e.g., corneal transplant surgery, cataract surgery). Corneal pachymetry using ultrasound is effective in aiding the early diagnosis and/or treatment of corneal transplant rejection, as well as assessing the response to treatment of corneal graft rejection. The procedure may be used to assess corneal graft health. Corneal pachymetry using ultrasound is also considered for assessing the risk of corneal decompensation before and after cataract surgery for individuals with endothelial disease.
References


American Academy of Ophthalmology. Glaucoma Panel. Preferred Practice Pattern® Guidelines. Primary Open-Angle Glaucoma Suspect. San Francisco, CA: American Academy of Opthalmology; 2015. Available at: http://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf. Accessed January 2, 2018.

American Academy of Optometry. Position paper on refractive surgery; section on cornea, contact lenses and refractive technologies. 2009. Available at: http://www.aaopt.org/content/docs/imagesPOSITION_PAPERS_CL/AAO%20CCLRT%20Refractive%20Surgery.pdf. [The link to this reference is no longer active on the AAO Web site.] Accessed November 27, 2013.

American Academy of Ophthalmology. Refractive Management/Intervention Panel. Preferred Practice Pattern® Guidelines. Refractive errors and refractive surgery. San Francisco, CA: American Academy of Opthalmology; 2017. Available at: https://www.aao.org/preferred-practice-pattern/refractive-errors-refractive-surgery-ppp-2017. Accessed January 2, 2018.

Brandt JD, Beiser JA, Kass MA, et al. Central corneal thickness in the ocular hypertension treatment study (OHTS). Ophthalmology. 2001;108(10):1779-1788.

Burka C, Lemke B. Measuring CCT? Plan to do it again. Review of Opthalmology 2005. Available at: http://www.revophth.com/content/d/research_review/i/1317/c/25343/. Accessed January 2, 2018.

Cheng AC, Rao SK, Lau S, et al. Central corneal thickness measurements by ultrasound, Orbscan II, and Visante OCT after LASIK for myopia. J Refract Surg. 2008;24(4):361-365.

Dueker D, Singh K, Lin S, et al. Corneal thickness measurement in the management of primary open-angle glaucoma: A report by the American Academy of Ophthalmology. Opthlamology. 2007;114:1779-1787.

Giraldez Fernandez MJ, Diaz Rey A, Cervino A, Yebra-Pimentel E. A comparison of two pachymetric systems: Slit-scanning and ultrasonic. CLAO J. 2002;28(4):221-223.

Kass MA, Heuer DK, Higginbotham EJ, et al. The ocular hypertension treatment study: a randomized trial determines that topical ocular hypertensive medication delays or prevents the onset of primary open-angle glaucoma. Archiv Ophthalmol. 2002;120(6):701-713.

Li EY, Mohamed S, Leung CK, et al. Agreement among 3 methods to measure corneal thickness: ultrasound pachymetry, orbscan II, and visante anterior segment optical coherence tomography. Ophthalmology. 2007;114(10):1842-1827.

Modis L Jr, Szalai E, Nemeth G, Berta A. Reliability of the corneal thickness measurements with the pentacam HR imaging system and ultrasound pachymetry. Cornea. 2011;30(5):561-566.

National Institute of Health. Results --ocular hypertension treatment study (OHTS). Available at: https://nei.nih.gov/glaucomaeyedrops/ohts_backg. Accessed January 2, 2018.

Palmberg P. Answers from the ocular hypertension treatment study. Arch Ophthalmol. 2002;120(6):829-830.

Phillips LJ, Cakanac CJ, Eger MW, Lilly ME. Central corneal thickness and measured IOP: A clinical study. Optometry. 2003;74(4):218-225.

Rainer G, Petternel V, Findl O, et al. Comparison of ultrasound pachymetry and partial coherence interferometry in the measurement of central corneal thickness. J Cataract Refract Surg. 2002;28(12):2142-2145.

Rainer G, Petternel V, Findl O, et al. Comparison of ultrasound pachymetry and partial coherence interferometry in the measurement of central corneal thickness. J Cataract Refract Surg. 2002;28(12):2142-2145.

Reinstein DZ, Silverman RH, Raevsky T. Arc-scanning very high-frequency digital ultrasound for 3D pachymetric mapping of the corneal epithelium and stroma in laser in situ keratomileusis. J Refract Surg. 2000;16(4):414-430.

Taravella M, Walker M. Postoperative corneal edema. [Medscape Web site]. Updated 03/03/2016. Available at: http://emedicine.medscape.com/article/1193218-overview. [via subscription only]. Accessed January 2, 2018.

Weissman BA, Yeung KK. Keratoconus. [Medscape Web site]. Updated 04/21/2016. Available at: http://emedicine.medscape.com/article/1194693-overview. [via subscription only]. Accessed January 2, 2018.

Wickham L, Edmunds B, Murdoch IE. Central corneal thickness: will one measurement suffice? Ophthalmology. 2005;112(2):225-228.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

76514


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Corneal Pachymetry Using Ultrasound
Description: ICD-10-CM codes




Policy History

Revisions for 07.13.07j:
04/02/2018This policy has undergone a routine review, and the following diagnosis codes have been:
  • Removed from Attachment A of this policy:
      H40.142 Capsular glaucoma with pseudoexfoliation of lens, left eye
      H40.143 Capsular glaucoma with pseudoexfoliation of lens, bilateral
  • Added to this policy:
      T85.398D Other mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
      T85.398S Other mechanical complication of other ocular prosthetic devices, implants and grafts, sequela

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 04/02/2018
Version Issued Date: 04/02/2018
Version Reissued Date: N/A

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