Marina Posted Thu 16th of May, 2013 17:09:46 PM
I am billing codes 99214 along with 92025 to Medicare.Is 92025 a covered procedure code and do I need to add a modifier to either code?
SuperCoder Answered Fri 17th of May, 2013 14:30:48 PM
Sometimes: Medicare covers diagnostic tests that are medically necessary according to Medicare guidelines. When performed for one of the diagnoses noted above, there should be no problem with coverage. For other corneal conditions, you may explain that there is a chance of non-coverage and ask the patient to sign an Advance Beneficiary Notice (ABN) and submit your claim with modifier GA.
Prior to cataract surgery, claims will be considered by Medicare administrative contractors if there is a diagnosis, in addition to cataract, supporting medical necessity. More often, testing with corneal topography prior to cataract surgery is associated with planning for concurrent limbal relaxing incisions; thus, it is not covered.
Corneal topography is not bundled by Medicare with either eye exams or other tests. Additionally, according to CPT instructions, corneal topography is not to be reported in conjunction with corneal transplant (65710-54755). Other payers may, of course, have different rules.
Some carriers may still find corneal topography to be "experimental or investigational." Consider having patients sign an advance beneficiary notice (ABN) before you perform this procedure. However, keep in mind that itcan be very difficult to get a patient to pay for a procedure that their insurance company considers "experimental."
92025 has MUE value of 1 only (also the code is "inherently bilateral"). , so cannot be billed multiple times.
This procedure is not covered under the following conditions:
• When performed pre- or post-operatively for non-Medi-Cal
covered refractive surgery procedures such as codes 65760 (kerato mileusis), 65765 (keratophakia), 65767 (epikeratoplasty), 65771 (radial keratotomy), 65772 (corneal relaxing incision) and 65775 (corneal wedge resection)
• When performed for routine screening purposes in the absence of associated signs, symptoms, illness or injury
Marina Posted Wed 22nd of May, 2013 16:50:25 PM
You mentioned "when performed for one of the diagnoses noted above", however I do not see any diagoses noted. What diagnoses are you referring to? I billed 99214 with dx's: 366.16, 375.15, 367.22 along with 92025 (same dx's were used). My claim was denied for reason "noncovered services because routine exam or screening proc done with a routine exam".
SuperCoder Answered Wed 22nd of May, 2013 22:32:11 PM
Please give us some time to evaluate the scenario. We will answer you with a definitive solution.
SuperCoder Answered Wed 29th of May, 2013 09:22:05 AM
Corneal topography is most frequently used for the diagnosis and management of corneal disease, disorders, abnormalities or injury. Commonly covered diagnoses include irregular astigmatism (367.22), keratoconus (371.60) and complication of corneal graft (996.51). Check your local coverage determination (LCD) policy for additional indications.
As we have indicated in previous answer, most payers tend to reject this claim citing the reason of "routine eye exam". In your case, that only seems to be the reason ["noncovered services because routine exam or screening proc done with a routine exam".]
In this case you can appeal with medical documentation, only if it was not a routine exam. Try to prove the medical necessity with a simple explanatory letter along with medical records, too. Bill the correct diagnosis code as per the medical records, not just a "suitable Dx code".