Local Coverage Determinations, known as LCDs. are the rules and regulations the particular Medicare Part B payer requires for specific testing services and surgical procedures. In an audit situation, your documentation should mirror the LCD requirements. Otherwise the payer may recoup or deny payment.
Your practice’s financial success also depends on knowing what diagnoses are payable for each CPT code. LCDs provide this information.
How to Find Payers’ Requirements
The Academy has compiled the current articles for each MAC so that physicians have quick access to their policies.
Another way to review payers’ policies is to find them on their website. Visit the Academy website to find your Medicare payer website URL.
- Each LCD comprises documentation guidelines and applicable ICD-10 codes.
- The coverage determination starts in draft stage either as a new or revised policy. After a 45-day comment window, the contractor determines the final policy, which becomes an active LCD.
- Administrative contractors can retire and archive policies.
Contractors may differ in the language of the policies offered on the same type of service. You should familiarize yourself with your Medicare administrative contractor’s ophthalmic LCDs to ensure your documentation meets the policy. When you follow the policies, Medicare will pay your claims appropriately and you can feel confident in any audit situation.
MAC Policy Lists as of Oct. 1, 2015
To find the entire policy, visit the Medicare coverage database.
Cahaba
L34252 - Drugs and Biologicals: Antiangiogenic Therapy for Ophthalmic Conditions
L34253 - Drugs and Biologicals: Botulinum Toxins
L34286 - Surgery: Blepharoplasty
L32487 - Surgery: Cataract Extraction
L34297 - Surgery: Removal of Benign or Premalignant Skin Lesions
L34301 - Surgery: YAG Capsulotomy
CGS
L33944 - Blepharoplasty
L33949 - Botulinum Toxins
L33946 - Capsule Opacification Following Cataract Surgery: Discission and YAG Capsulotomy
L33954 - Cataract Surgery
L34370 - Category III CPT Codes
L34008 - Computerized Corneal Topography
L33999 - Corneal Pachymetry
L34171 - Nasal Punctum- Nasolacrimal Duct Dilation and Probing with or without Irrigation
L34393 - Ocular Photography- External
L34175 - Ophthalmic Angiography (Fluorescein and Indocyanine Green)
L34181 - Ophthalmic Biometry for Intraocular Lens Power Calculation
L34399 - Ophthalmoscopy: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
L34064 - Panretinal (Scatter) Laser Photocoagulation
L34200 - Removal of Benign Lesions
L34061 - Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L34394 - Visual Fields Testing
First Coast
L36237 - Amniotic Membrane- Sutureless Placement on the Ocular Surface
L33274 - Botulinum Toxins
L33904 - B-Scan
L33808 - Cataract Extraction
L33810 - Computerized Corneal Topography
L36232 - Diagnostic Evaluation and Medical Management of Moderate-Severe Dry Eye Disease (DED)
L33813 - Destruction of Malignant Skin Lesions -
L33818 - Excision of Malignant Skin Lesions
L33819 - External Ocular Photography
L33997 - Fluorescein Angiography
L33670 - Fundus Photography
L34000 - Ganciclovir and Cidofovir
L33377 - Implantable Miniature Telescope
L33911 - Indocyanine-Green Angiography
L33504 - Intravitreal Bevacizumab (Avastin®)
L33914 - Iridotomy by Laser Surgery
L33916 - Lacrimal Punctal Plugs
L33917 - Laser Trabeculoplasty
L33919 - Macugen (pegaptanib sodium injection)
L33777 - Noncovered Services
L33705 - Ocular Photodynamic Therapy (OPT) with Verteporfin
L33925 - Ophthalmological Diagnostic Services
L34017 - Ophthalmoscopy
L33927 - Optical Coherence Biometry
L33407 - Ranibizumab (Lucentis™)
L33751 - Scanning Computerized Ophthalmic Diagnostic Imaging
L34028 - Upper Eyelid & Brow Surgical Proc.
L33766 - Visual Field Examinations
L33968 - Yag Laser Capsulotomy
NGS
L33646 - BotulinumToxins
L33558 - Cataract Extraction
L33392 - Category III CPT® Codes
L33630 - Corneal Pachymetry
L33394 - Drugs and Biologicals, Coverage, for Label and Off-Label Uses
L33584 - Implantable Miniature Telescope (IMT)
L33621 - Ophthalmic Biometry for Intraocular Lens Power Calculation
L33567 - Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)
L33628 - Panretinal (Scatter) Laser Photocoagulation
L34380 - Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
L33574 - Visual Fields Testing
Noridian
JE:
L34188 - Actinic Keratosis
L34194 - Blepharoplasty, Blepharoptosis and Brow Lift
L35170 - Botulinum Toxin Types A and B Policy
L34203 - Cataract Surgery in Adults
L34233 - Skin Lesion (Non-Melanoma) Removal
JF
L36286 - Blepharoplasty, Eyelid Surgery, and Brow Lift
L35172 - Botulinum Toxin Types A and B
L35008 - Non-Covered Services
L33979 - Skin Lesion Removal (Includes AK and Excludes MOHS)
Novitas
L34966 - Benign Skin Lesions
L35091 - Cataract Extraction (including Complex Cataract Surgery)
L34862 - Co-Management of Surgical Procedures
L35087 - Glaucoma Treatment with Aqueous Drainage Device
L35095 - Lacrimal Punctum Plugs
L35038 - Scanning Computerized Ophthalmic Diagnostic Imaging
L35004 - Surgery: Blepharoplasty
Palmetto GBA
L33765 - Blepharoplasty Eyelid Surgery, and brow lift
L34413 - Cataract Surgery
L33458 - Chemodenervation
L34512 - Corneal Pachymetry
L34555 - Non-Covered Category III CPT Codes
L33467 - Ophthalmology: Extended Ophthalmoscopy and Fundus Photography
L33445 - Removal of Benign and Malignant Skin Lesions
WPS
L34528 - Blepharoplasty, Blepharoptosis and Brow Lift
L34635 - Botulinum Toxin Type A & Type B
L34590 - Category III Codes
L35053 - Chemotherapy Drugs and their Adjuncts
L34741 - Drugs and Biologics (Non-chemotherapy)
L34532 - Low Vision Services
L35498 - Removal of Benign Skin Lesions
L34760 - Scanning Computerized Ophthalmic Diagnostic Imaging
L34615 - Visual Fields
* * *
About the authors: Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series. Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She oversees the Academy’s Chart Auditing Service and is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series.