• What You Need to Know About Local Coverage Determinations

    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 best way to review payers’ policies is to find them on their website. Visit the Academy website to find your Medicare payer website URL.

    • The 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.