Coding for corneal surgery requires distinction between cosmetic and functional

Four new cornea CPT codes are available in 2004; do not be creative with them, one specialist advises.

Issue: February 1, 2004

ByRiva Lee Asbell

With the introduction of several new Current Procedural Terminology codes for cornea, corneal coding is in the spotlight for 2004. Many Medicare carriers have local medical review policies regarding corneal surgery.

Corneal surgery is similar to oculoplastic surgery because it has procedures that are either cosmetic or functional. Functional procedures usually are covered services for Medicare, whereas other procedures may not be payable due to the ambiguous nature of the procedure/diagnosis. Thus, the insurer regards the procedure as cosmetic, and it will not be covered. In cornea, the usual reason for this is that the diagnosis relates to a primary refractive error.

Refractive keratoplasty

Refractive keratoplasty has gained prominence as a term used for surgery that reshapes the cornea to correct refractive errors such as myopia, hyperopia and astigmatism. Do not confuse the use of the word keratoplasty applied to refractive surgery and the most common usage of the term, which is for corneal transplant surgery.

The HGSA Administrators (PA Medicare Carrier) policy on “Corneal Surgery to Correct Refractive Errors,” for example, includes the following procedures as falling into the category of refractive keratoplasty:

Keratomileusis (CPT code 65760)
Keratophakia (CPT code 65765)
Epikeratoplasty (CPT code 65767)
RK (CPT code 65771)
PRK (CPT code 66999 — the unlisted code)
LASIK (CPT code 66999 — the unlisted code)
Conductive keratoplasty (CPT code 66999 — the unlisted code)

It further clarifies which codes are considered cosmetic and those that are not.

Astigmatism correction

Medicare only pays for the surgical correction of astigmatism when the astigmatism has been surgically induced or resulted from ocular trauma. The applicable CPT codes are 65772 (corneal relaxing incision for correction of surgically induced astigmatism) and 65775 (corneal wedge resection for correction of surgically induced astigmatism).

If neither of these codes is appropriate, you may have to use CPT code 66999 — the unlisted code. HGSA Administrators wants 66999 used for reporting the repair of surgically induced astigmatism resulting from trauma. When coding for repair of surgically induced astigmatism, be sure to read your carrier’s local medical review policy (LMRP). Diagnosis coding plays a critical role in this.

Astigmatic keratotomy and limbal relaxing incisions performed at the time of cataract surgery are not covered and cannot be billed to Medicare unless the astigmatism was induced from prior surgery or trauma. Therefore, many providers are now charging the patient for these procedures. This requires close scrutiny on the part of the practice to ascertain if there is medical necessity for the procedure and when it should be performed. Surgical techniques, the amount of preoperative planning and the amount of presurgical astigmatism should be considered before the patient is charged. There would hardly ever be medical necessity for performing one of these procedures whenever cataract surgery is performed.

LASIK

Some carriers do cover LASIK when the procedure is performed for certain qualifying conditions. For payment from Noridian, for example, all of the following conditions must be met:

Surgically induced astigmatism or anisometropia.
Inability to wear glasses or contact lenses after surgery due to the above conditions.
Documented attempts to correct the surgical error with glasses or contact lenses.
Presence of a 2.5 D or more increase in astigmatism and/or anisometropia from the preoperative to postoperative state.

The patient’s primary problem is not corneal graft rejection or multiple failures when the primary goal may be comfort rather than vision improvement.

The laser used must be approved by the Food and Drug Administration for this indication.

The use of the excimer laser to repair surgically induced astigmatism and/or anisometropia is considered ocular surgery. Covera ners who have complied with FDA regulations and practitioners with training in the surgical management of the disease or condition being treated per CIM 35-52.

Advanced beneficiary notice

It is always wise to have an advanced beneficiary notice signed preoperatively by the patient in the above instances, as well as any others where there may be some questionable postoperative concerns about financial responsibility if the carrier deems the procedure cosmetic and not functional.

New CPT codes

The new 2004 CPT codes that pertain to cornea coding are:

65780: Ocular surface reconstruction; amniotic membrane transplantation.
65781: Limbal stem cell allograft (eg, cadaveric or living donor).
65782: Limbal conjunctival autograft (includes obtaining graft).
68371: Harvesting conjunctival allograft, living donor.

Amniotic membrane and limbal stem cell transplants are performed to treat many of the following conditions/diagnoses: corneal pannus and/or superficial corneal scarring, persistent corneal epithelial defects, corneal perforation, neurotrophic keratitis, persistent corneal epithelial defects, bullous keratopathy, corneal thinning, corneal ulcer, chemical burns of the ocular surface, pterygia, Stevens-Johnson syndrome, limbal stem cell insufficiency and high-risk corneal transplants. Of course, not all of these diagnoses apply to all of these procedures.

Other coding

I caution you not to be overly creative in coding some of these corneal procedures. CPT instructions mandate that if there is no code to exactly describe a given surgical procedure, then the unlisted code should be used, in this case CPT code 66999. An example of erroneous creativity was the recommendation to use CPT code 65710 (lamellar keratoplasty) for amniotic membrane graft for cases done before January 1, 2004. This would not be acceptable.

If a device used in surgery is not FDA approved, then Medicare considers it experimental, and the patient has to pay for the operation.

Keratoconus. One of the surgical corrections for keratoconus is the insertion of intrastromal corneal rings. Because there is no specific code for this procedure, you must code it using CPT code 66999.

Deep lamellar keratoplasty. I code this procedure using CPT code 65710 (keratoplasty (corneal transplant); lamellar). For coders, lamellar keratoplasty refers to removal/replacement of a layer (lamella) of the cornea whereas penetrating keratoplasty refers to removal/replacement of full thickness corneal tissue.

PTK vs. PRK. Phototherapeutic keratectomy is usually a covered service for Medicare, and the LMRP’s set the parameters for coding. PRK, on the other hand, is considered a cosmetic procedure and generally is not a covered service. Most carriers process PTK using the unlisted procedure code 66999.

Diagnostic tests. Pachymetry received a CPT category I code in 2004 (76514). Many of the Medicare policies restrict its usage to once in a lifetime for glaucoma diagnoses. However, multiple tests are allowed when used in various procedures connected to corneal surgery. This is a work in progress, and the indications, frequency limits, diagnoses and technologies are changing in the different policies. For example, the Wisconsin carrier allows pachymetry by laser interferometry to be billed with the CPT code 76514. If not addressed in a LMRP, bill pachymetry by laser interferometry using CPT code 92499.

Corneal topography is reimbursed using the unlisted CPT procedure code for special ophthalmic diagnostic tests (92499). The usual diagnoses that are acceptable for payment are irregular astigmatism, keratoconus and pre- and postcorneal transplant surgery. Be sure to check your carrier’s LMRP since there may also be specific billing instructions.

For Your Information:

Riva Lee Asbell can be reached at Riva Lee Asbell Associates, One Independence Place, Suite 507, 241 South Sixth St., Philadelphia, PA 19106; (215) 629-9221; fax: (215) 629-9042; e-mail: rivalee@aol.com.

CPT codes, copyright 2003, American Medical Association.