LCD L34181: Ophthalmic Biometry for Intraocular Lens Power Calculation

Abstract:

There are two methods used for intraocular lens power calculation:

• A-Scan Ultrasound Ophthalmic Biometry

Ophthalmic A-scan biometry by ultrasound echography is performed through the optical axis of the eye to determine the power of an intraocular (IOL) lens implant. The technical portion of ophthalmic biometry is usually performed in both eyes at the same setting.

• Non-Ultrasound Ophthalmic Biometry

Optical coherence biometry (OCB) utilizes partial coherence interferometry for measuring axial length (biometry) and for intraocular lens power calculation when planning for cataract surgery. OCB also measures the corneal curvature and anterior chamber depth. The technical portion is usually performed in both eyes at the same visit.

Indications:

Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used. (CMS Publication 100-03, Medicare National Coverage Determinations Manual , Chapter 1, Part 1, Section 10.1)

Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented. (CMS Publication 100-03, Medicare National Coverage Determinations Manual , Chapter 1, Part 1, Section 10.1?)

Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carrier’s medical staff, they are covered. (CMS Publication 100-03, Medicare National Coverage Determinations Manual , Chapter 1, Part 1, Section 10.1)

A second complete A scan/OCB will be covered if a different surgeon, unaffiliated with the surgeon who performed the first cataract extraction, performed the extraction on the second eye. We would not anticipate a high frequency of these instances.

Limitations:

Currently, the relative value units (RVUs) for the global and technical components of each method of ophthalmic biometry for intraocular lens power calculation are based on the procedure being bilaterally performed. If unilateral cataract extraction with an IOL implant is planned, a bilateral technical component of the A-scan or OCB is typically performed, while the professional component of the power calculation is performed unilaterally (on the operative eye only). Thus, the technical components are considered bilateral and the professional component is considered unilateral.

Prior to cataract surgery on the second, contralateral eye, allowance for the power calculation can be made. However, allowance for the technical component of the A-scan or OCB CPT code cannot be made since this bilateral procedure was performed and reimbursed at the time of the first surgery.

The technical component of the scan will generally provide valid information for twelve months. A repeat scan in less than twelve months would not be covered without documentation of significant change in vision (unless required because a second unaffiliated surgeon performed the second cataract extraction.) Generally, when bilateral cataracts are noted at examination, extraction of the second cataract is only performed after results of the first cataract extraction are known and symptoms or findings support the medical necessity for removal of the cataract in the other eye. If ophthalmic biometry is performed and later the surgery is canceled, it is reasonable to allow a repeat scan if significant time, e.g., greater than one (1) year, has elapsed when surgery is rescheduled.

Ophthalmic biometry for lens power calculation should not be performed unless a decision to remove the cataract has been made by the patient and surgeon. If the biometry is performed by an optometrist, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If the biometry is repeated by the operating surgeon due to inadequacy of the study, the original eye care physician/provider should anticipate not being reimbursed for the study.

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