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National Coverage Determination (NCD)

Endothelial Cell Photography

80.8

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Tracking Information

Publication Number
100-3
Manual Section Number
80.8
Manual Section Title
Endothelial Cell Photography
Version Number
1
Effective Date of this Version
08/31/1992
Ending Effective Date of this Version
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Endothelial cell photography involves the use of a specular microscope to determine the endothelial cell count. It is used by ophthalmologists as a predictor of success of ocular surgery or certain other ocular procedures.
Indications and Limitations of Coverage

Endothelial cell photography is a covered procedure under Medicare when reasonable and necessary for patients who meet one or more of the following criteria:

  • Have slit lamp evidence of endothelial dystrophy (cornea guttata),
  • Have slit lamp evidence of corneal edema (unilateral or bilateral),
  • Are about to undergo a secondary intraocular lens implantation,
  • Have had previous intraocular surgery and require cataract surgery,
  • Are about to undergo a surgical procedure associated with a higher risk to corneal endothelium; i.e., phacoemulsification, or refractive surgery (see §80.7 for excluded refractive procedures),
  • With evidence of posterior polymorphous dystrophy of the cornea or irido-corneal-endothelium syndrome, or
  • Are about to be fitted with extended wear contact lenses after intraocular surgery.

When a pre-surgical examination for cataract surgery is performed and the conditions of this section are met, if the only visual problem is cataracts, endothelial cell photography is covered as part of the presurgical comprehensive eye examination or combination brief/intermediate examination provided prior to cataract surgery, and not in addition to it. (See §10.1.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
61
Revision History

08/1992 - Stipulated that endothelial cell photography subject to the limitation on coverage of visual tests prior to cataract surgery. Effective date 08/31/1992. (TN 61) 
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Endothelial Cell Photography 1 08/31/1992 - N/A You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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