Optometry and Ophthalmology

Access the below information from this page.

National Coverage Determinations (NCDs)

Noridian processes claims following NCD guidelines which include the below topics:

  • Hydrophilic Contact Lens for Corneal Bandage
  • Photodynamic Therapy including Ocular Photodynamic Therapy (OPT)
  • Photosensitive Drugs
  • Hydrophilic Contact Lenses
  • Scleral Shell
  • Intraocular Photography
  • Refractive Keratoplasty
  • Keratoplasty
  • Endothelial Cell Photography
  • Computer Enhanced Perimetry
  • Phaco-Emulsification Procedure - Cataract Extraction
  • Vitrectomy
  • Intraocular Lenses (IOLs)

Coverage

Medicare may cover items or services if they satisfy three basic requirements.

  1. Must fall within a statutorily defined benefit category;
  2. Services must be reasonable and necessary; and
  3. Per CMS guidelines, item or service must not be excluded from coverage

Medicare only pays for services that are reasonable and necessary to diagnose or treat the patient. While Medicare rules may make exceptions or specifications for certain services, it is important to understand that medical necessity is what decides whether most Medicare services may or may not pay.

Covered/Noncovered Services

The following are not all-inclusive lists.

Services Details
Covered Services
  • Glaucoma Screening: If beneficiary is high-risk, Medicare covers a glaucoma screening once every 12 months. A high-risk beneficiary must include a family history of glaucoma, African Americans ages 50 or older, Hispanic Americans ages 65 or older or if patient is diabetic. Screening must include a dilated eye exam with intraocular pressure measurement as well as direct ophthalmoscopy exam or slit lamp biomicroscopic exam
  • Diagnosis of Cataracts: For diagnosis of cataracts, Medicare covers one comprehensive eye examination or combination of a brief/intermediate examination not to exceed charge of a comprehensive examination. 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.
  • Conventional IOLs implanted during cataract surgery
  • Facility and physician services, and the supplies that are required to insert a conventional IOL during cataract surgery
  • One pair of eyeglasses or contact lenses as a prosthetic device which are furnished after each cataract surgery with insertion of an IOL
  • Post-cataract services provided by optometrist may be covered if the optometrist is licensed to provide this service in state
  • Eye exams to evaluate for eye disease for patients with diabetes or signs and symptoms of eye disease
  • Certain diagnostic tests and treatments for patient with age-related macular degeneration
Noncovered Services
  • Routine eye exams
  • Refraction
  • Insertion of P-C or A-C IOL instead of conventional IOL
  • Additional services required to insert or monitor P-C IOL or A-C IOL

An Advance Beneficiary Notice of Noncoverage (ABN) is not required for noncovered services; however, one may be given to the beneficiary as a courtesy.

 

Billing

Common modifiers used with eye care services are:

  • E1: Upper left, eyelid
  • E2: Lower left, eyelid
  • E3: Upper right, eyelid
  • E4: Lower right, eyelid
  • RT: Right side of body
  • LT: Left side of body
  • 50: Bilateral procedure

Note: Cataract CPT codes 66982-66986 should not be billed with modifiers E1, E2, E3, and E4.

Intravitreal Injections

  • Avastin (HCPCS J7999): Include name of drug and dosage in Item 19 of CMS-1500 claim form or electronic equivalent
  • Lucentis (HCPCS J2778) and Eylea (HCPCS J0178): Include number of units as dosage given
    • Description is not required in Item 19 of CMS-1500 claim form

If information is missing the claim will be denied as unprocessable

Resources

 

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