Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27507
LCD Title
Ophthalmic A and B Scans
Contractor’s Determination Number
L27507
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Primary Geographic Jurisdiction
Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after N/A
Revision Ending Date
N/A
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Ocular ultrasonography involves the transmission of high-frequency sound waves through the eye and the measurement of their reflection from ocular structures. An A-scan converts the resulting echoes into waveforms whose crests represent the positions of different structures. The B-scan converts the echoes into patterns of dots that form a two-dimensional, cross-sectional image of the ocular structure.
Ocular and orbital echography and sonography, jointly referred to as ultrasonography, are medically appropriate diagnostic tools to diagnose and/or follow ocular and orbital pathologies.
The indications for diagnostic ultrasound fall into the following broad categories:
- Axial length determination
- Endophthalmitis evaluation
- Intraocular/orbital foreign body evaluation
- Intraocular tumor differentiation
- Miotic pupil (pupil that is incapable of being dilated)
- Ocular trauma
- Opaque media, e.g., corneal scars, mature cataract, vitreous hemorrhage
- Orbital tumors and extraocular muscle evaluation
- Retinal detachment, choroidal detachment, membrane differentiation
The use of ultrasound to make IOL calculatons is addressed in a separate policy entitled “Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation”.
Coverage Topic
Diagnostic Tests and X-Rays
Coding Information
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
051X | Clinic-general classification |
076X | Treatment or observation room-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
76510 | OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE A-SCAN PERFORMED DURING THE SAME PATIENT ENCOUNTER |
76511 | OPHTHALMIC ULTRASOUND, DIAGNOSTIC; QUANTITATIVE A-SCAN ONLY |
76512 | OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN (WITH OR WITHOUT SUPERIMPOSED NON-QUANTITATIVE A-SCAN) |
76513 | OPHTHALMIC ULTRASOUND, DIAGNOSTIC; ANTERIOR SEGMENT ULTRASOUND, IMMERSION (WATER BATH) B-SCAN OR HIGH RESOLUTION BIOMICROSCOPY |
76529 | OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED | |
198.89 | SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
BENIGN NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - BENIGN NEOPLASM OF EYE PART UNSPECIFIED | |
228.03 | HEMANGIOMA OF RETINA |
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM | |
246.8 | OTHER SPECIFIED DISORDERS OF THYROID |
PURULENT ENDOPHTHALMITIS UNSPECIFIED - VITREOUS ABSCESS | |
360.21 | PROGRESSIVE HIGH (DEGENERATIVE) MYOPIA |
360.50 | FOREIGN BODY MAGNETIC INTRAOCULAR UNSPECIFIED |
360.51 | FOREIGN BODY MAGNETIC IN ANTERIOR CHAMBER OF EYE |
360.52 | FOREIGN BODY MAGNETIC IN IRIS OR CILIARY BODY |
360.54 | FOREIGN BODY MAGNETIC IN VITREOUS |
360.61 | FOREIGN BODY IN ANTERIOR CHAMBER |
360.62 | FOREIGN BODY IN IRIS OR CILIARY BODY |
360.64 | FOREIGN BODY IN VITREOUS |
RETINAL DETACH WITH RETINAL DEFECT UNSPECIFIED - OLD RETINAL DETACH TOTAL OR SUBTOTAL | |
361.12 | BULLOUS RETINOSCHISIS |
361.2 | SEROUS RETINAL DETACH |
RETINAL DEFECT UNSPECIFIED - MULTIPLE DEFECTS OF RETINA WITHOUT DETACH | |
TRACTION DETACH OF RETINA - OTHER FORMS OF RETINAL DETACH | |
361.9 | UNSPECIFIED RETINAL DETACH |
362.21 | RETROLENTAL FIBROPLASIA |
RETINAL LAYER SEPARATION UNSPECIFIED - HEMORRHAGIC DETACH OF RETINAL PIGMENT EPITHELIUM | |
CHOROIDAL DEGENERATION UNSPECIFIED - ANGIOID STREAKS OF CHOROID | |
363.50 | HEREDITARY CHOROIDAL DYSTROPHY OR ATROPHY UNSPECIFIED |
363.62 | EXPULSIVE CHOROIDAL HEMORRHAGE |
CHOROIDAL DETACH UNSPECIFIED - HEMORRHAGIC CHOROIDAL DETACH | |
363.8 | OTHER DISORDERS OF CHOROID |
364.05 | HYPOPYON |
364.41 | HYPHEMA OF IRIS AND CILIARY BODY |
365.02 | ANATOMICAL NARROW ANGLE BORDERLINE GLAUCOMA |
365.41 | GLAUCOMA ASSOCIATED WITH CHAMBER ANGLE ANOMALIES |
NONSENILE CATARACT UNSPECIFIED - OTHER AND COMBINED FORMS OF NONSENILE CATARACT | |
SENILE CATARACT UNSPECIFIED - OTHER AND COMBINED FORMS OF SENILE CATARACT | |
TRAUMATIC CATARACT UNSPECIFIED - PARTIALLY RESOLVED TRAUMATIC CATARACT | |
CATARACTA COMPLICATA UNSPECIFIED - CATARACT IN DEGENERATIVE OCULAR DISORDERS | |
DIABETIC CATARACT - CATARACT ASSOCIATED WITH RADIATION AND OTHER PHYSICAL INFLUENCES | |
AFTER-CATARACT UNSPECIFIED - AFTER-CATARACT OBSCURING VISION | |
366.8 | OTHER CATARACT |
366.9 | UNSPECIFIED CATARACT |
368.03 | REFRACTIVE AMBLYOPIA |
CORNEAL OPACITY UNSPECIFIED - PHTHISICAL CORNEA | |
CORNEAL EDEMA UNSPECIFIED - CORNEAL EDEMA DUE TO WEARING OF CONTACT LENSES | |
371.43 | BAND-SHAPED KERATOPATHY |
ACUTE INFLAMMATION OF ORBIT UNSPECIFIED - ORBITAL TENONITIS | |
CHRONIC INFLAMMATION OF ORBIT UNSPECIFIED - PARASITIC INFESTATION OF ORBIT | |
THYROTOXIC EXOPHTHALMOS - EXOPHTHALMIC OPHTHALMOPLEGIA | |
EXOPHTHALMOS UNSPECIFIED - LATERAL DISPLACEMENT OF GLOBE | |
DEFORMITY OF ORBIT UNSPECIFIED - DEFORMITY OF ORBIT DUE TO TRAUMA OR SURGERY | |
ENOPHTHALMOS UNSPECIFIED AS TO CAUSE - ENOPHTHALMOS DUE TO TRAUMA OR SURGERY | |
376.6 | RETAINED (OLD) FOREIGN BODY FOLLOWING PENETRATING WOUND OF ORBIT |
ORBITAL CYSTS - OTHER ORBITAL DISORDERS | |
376.9 | UNSPECIFIED DISORDER OF ORBIT |
377.00 | PAPILLEDEMA UNSPECIFIED |
377.21 | DRUSEN OF OPTIC DISC |
377.24 | PSEUDOPAPILLEDEMA |
377.43 | OPTIC NERVE HYPOPLASIA |
379.07 | POSTERIOR SCLERITIS |
379.21 | VITREOUS DEGENERATION |
379.22 | CRYSTALLINE DEPOSITS IN VITREOUS |
379.23 | VITREOUS HEMORRHAGE |
379.24 | OTHER VITREOUS OPACITIES |
379.42 | MIOSIS (PERSISTENT) NOT DUE TO MIOTICS |
379.60 | INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, UNSPECIFIED |
379.61 | INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 1 |
379.62 | INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 2 |
379.63 | INFLAMMATION (INFECTION) OF POSTPROCEDURAL BLEB, STAGE 3 |
379.8 | OTHER SPECIFIED DISORDERS OF EYE AND ADNEXA |
DISORDER OF EYE UNSPECIFIED - OTHER ILL-DEFINED DISORDERS OF EYE | |
CLINICAL ANOPHTHALMOS UNSPECIFIED - CRYPTOPHTHALMOS | |
MICROPHTHALMOS UNSPECIFIED - MICROPHTHALMOS ASSOCIATED WITH OTHER ANOMALIES OF EYE AND ADNEXA | |
BUPHTHALMOS UNSPECIFIED - BUPHTHALMOS ASSOCIATED WITH OTHER OCULAR ANOMALIES | |
CONGENITAL CATARACT UNSPECIFIED - OTHER CONGENITAL CATARACT AND LENS ANOMALIES | |
743.51 | VITREOUS ANOMALIES CONGENITAL |
871.0 | OCULAR LACERATION WITHOUT PROLAPSE OF INTRAOCULAR TISSUE |
871.1 | OCULAR LACERATION WITH PROLAPSE OR EXPOSURE OF INTRAOCULAR TISSUE |
871.2 | RUPTURE OF EYE WITH PARTIAL LOSS OF INTRAOCULAR TISSUE |
871.5 | PENETRATION OF EYEBALL WITH MAGNETIC FOREIGN BODY |
871.6 | PENETRATION OF EYEBALL WITH (NONMAGNETIC) FOREIGN BODY |
921.3 | CONTUSION OF EYEBALL |
996.69 | INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICE IMPLANT AND GRAFT |
998.82 | CATARACT FRAGMENTS IN EYE FOLLOWING CATARACT SURGERY |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Only one A-scan or one B-scan is allowed in a twelve-month time period. If these services are required more than once during a twelve-month period, a copy of the medical record that supports the medical necessity of the additional procedure(s) may be requested for review.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27507
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
07/01/2008 |
L27507 |
Utilization Guidelines revised--records must be available for review; submission not required. |
05/23/2008 |
L27507 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D31 |
Original LCD posted for comment. |
Last Reviewed On
06/30/2008
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