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
- Endothelial Cell Photography
- Computer Enhanced Perimetry
- Phaco-Emulsification Procedure - Cataract Extraction
- Intraocular Lenses (IOLs)
Medicare may cover items or services if they satisfy three basic requirements.
- Must fall within a statutorily defined benefit category;
- Services must be reasonable and necessary; and
- 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.
The following are not all-inclusive lists.
|Covered Services|| |
|Noncovered Services|| |
An Advance Beneficiary Notice of Noncoverage (ABN) is not required for noncovered services; however, one may be given to the beneficiary as a courtesy.
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.
- 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
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 280.1
- CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 80
Last Updated Aug 24, 2018
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.