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MP 9.03.05 Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy

 

Medical Policy    
Section
Miscellaneous Policies
 
Original Policy Date
11/1/97
Last Review Status/Date
Reviewed with literature search/4:2013
Issue
4:2013
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Computer-assisted topography/photokeratoscopy provides a quantitative measure of corneal curvature. Measurement of corneal topography is being evaluated for the diagnosis and follow-up of corneal disorders such as keratoconus, difficult contact lens fits, and pre- and postoperative assessment of the cornea, most commonly after refractive surgery.

Background

Corneal topography describes measurements of the curvature of the cornea. An evaluation of corneal topography is necessary for the accurate diagnosis and follow-up of certain corneal disorders, such as keratoconus, difficult contact lens fits, and pre- and postoperative assessment of the cornea, most commonly after refractive surgery. Various techniques and instruments are available to measure corneal topography:

  • The keratometer (also referred to as an ophthalmometer), the most commonly used instrument, projects an illuminated image onto a central area in the cornea. By measuring the distance between a pair of reflected points in both of the cornea’s two principal meridians, the keratometer can estimate the radius of curvature of two meridians. The fact that the keratometer can only estimate the corneal curvature over a small percentage of its surface and that estimates are based on the frequently incorrect assumption that the cornea is spherical, are limitations of this technique.
  • The keratoscope is an instrument that reflects a series of concentric circular rings off the anterior corneal surface. Visual inspection of the shape and spacing of the concentric rings provides a qualitative assessment of topography. A photokeratoscope is a keratoscope equipped with a camera that can provide a permanent record of the corneal topography.
  • Computer-assisted photokeratoscopy is an alternative to keratometry or keratoscopy in measuring corneal curvature. This technique uses sophisticated image analysis programs to provide quantitative corneal topographic data. Early computer-based programs were combined with keratoscopy to create graphic displays and high-resolution color-coded maps of the corneal surface. Newer technologies measure both curvature and shape, enabling quantitative assessment of corneal depth, elevation, and power.

Regulatory Status

A number of devices have received clearance for marketing through the U.S. Food and Drug Administration (FDA) 510(k) mechanism. The Orbscan® (manufactured by Orbtek and distributed by Bausch and Lomb) received FDA clearance in 1999. The second generation Orbscan II is a hybrid system that uses both projective (slit scanning) and reflective (Placido) methods. The Pentacam® (Oculus) is one of a number of rotating Scheimpflug imaging systems produced in Germany.


Policy

Non-computer assisted corneal topography is considered part of the evaluation/and management services of general ophthalmological services (CPT codes 92002–92014), and therefore this service should not be billed separately. There is no separate CPT code for this type of corneal topography.

Computer-assisted corneal topography is considered not medically necessary to detect or monitor diseases of the cornea.

 


Policy Guidelines

Effective January 1, 2007, there is a specific CPT code for computer-assisted corneal topography:

92025: Computerized corneal topography, unilateral or bilateral, with interpretation and report.

Non-computer-assisted corneal topography should be considered inclusive to evaluation and management services.


Benefit Application

BlueCard/National Account Issues

State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

Some of these services may be provided as part of care that is not generally covered under health insurance contracts, such as:

  • Contact lens fitting
  • Refractive surgery

Thus, review for these services excluded by the contract may also be needed.


Rationale

This policy was created in 1997 and updated periodically using the MEDLINE database. The most recent literature update was performed for through March 13, 2013.

Detection and Monitoring Diseases of the Cornea

Assessing corneal topography has been done for many years and is a part of the standard ophthalmologic examination of some patients. (1, 2) However, corneal topography can be evaluated and determined in multiple ways. Computer-assisted corneal topography has been used for early identification and quantitative documentation of the progression of keratoconic corneas, and evidence is sufficient to indicate that computer-assisted topographical mapping can detect and monitor disease. However, the question that is pertinent to this policy is whether quantitative measurement results in an intervention change that improves health outcomes.

Contact Lens Fitting in Patients with Keratoconus

A 2010 study was identified on computer-assisted corneal topography for the design of gas-permeable contact lens in 30 patients with keratoconus, who were recruited for the study in 2005-2006. (3) The report indicates that the subjects were consecutive, although patients whose topographical plots could not be used were excluded (number not described). The fit of the new lens was compared with the fit of the patient’s habitual lens (randomized order on the same day). Clinical evaluation showed a good fit (no or minor modification needed) for more than 90% of the computer-designed lens. However, progression of keratoconus causes a bias favoring the most recently fitted lens, confounding the comparison between the new computer-designed lens and the patient’s habitual lens. This study has substantial limitations in both design and reporting.

Corneal Astigmatism Measurements for Toric Intraocular Lens Implantation

In 2012, Lee et al. reported a prospective comparative study of 6 methods of measuring corneal astigmatism for the purpose of toric intraocular lens implantation. (4) Astigmatism was evaluated in 257 eyes (141 patients) using manual keratometry, autokeratometry, partial coherence interferometry (IOLMaster®), ray-tracing aberrometry (iTrace™), scanning-slit topography (Orbscan), and Scheimpflug imaging (Pentacam). All measurements were masked to the results for the other instruments. The study found no significant difference between the different instruments, indicating no advantage to computerized corneal topography compared to manual keratometry.

Summary

With the exception of refractive surgery, a service not generally covered as a health insurance benefit, no studies have shown clinical benefit (e.g., a change in treatment decisions) from a quantitative rather than qualitative evaluation of corneal topography. Therefore, due to the additional cost of this procedure and a lack of scientific evidence from appropriately constructed clinical trials that confirm improved health outcomes, quantitative evaluation of corneal topography, including evaluation with computer assistance, is considered not medically necessary.

Practice Guidelines and Position Statements

A 1999 American Academy of Ophthalmology (AAO) assessment indicates that computer-assisted corneal topography evolved from the need to measure corneal curvature and topography more comprehensively and accurately than keratometry and that corneal topography is used primarily for refractive surgery. (5) The AAO indicates several other potential uses: 1) evaluate and manage patients following penetrating keratoplasty, 2) plan astigmatic surgery, 3) evaluate patients with unexplained visual loss and document visual complications, and 4) fit contact lenses. However, the AAO assessment noted that data are lacking to support the use of objective measurements, as opposed to subjective determinants (subjective refraction) of astigmatism.

Medicare National Coverage

There is no national Medicare coverage decision for this testing.

References:

  1. Morrow GL, Stein RM. Evaluation of corneal topography: past, present and future trends. Can J Ophthalmol 1992; 27(5):213–25.
  2. Wilson SE, Klyce SD. Advances in the analysis of corneal topography. Surv Ophthalmol 1991; 35(4-Jan):269–77.
  3. Bhatoa NS, Hau S, Ehrlich DP. A comparison of a topography-based rigid gas permeable contact lens design with a conventionally fitted lens in patients with keratoconus. Cont Lens Anterior Eye 2010; 33(3):128-35.
  4. Lee H, Chung JL, Kim EK et al. Univariate and bivariate polar value analysis of corneal astigmatism measurements obtained with 6 instruments. J Cataract Refract Surg 2012; 38(9):1608-15.
  5. Ophthalmic Technology Assessment Committee Cornea Panel American Academy of Ophthalmology. Corneal topography. Ophthalmology 1999; 106(8-Jan):1628-38.

 

 

Codes

Number

Description

CPT  92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report (effective 1/1/07) 
  92002–92014  General ophthalmological services 
ICD-9 Procedure  95.02  Comprehensive eye examination 
  95.09  Eye examination, not otherwise specified 
ICD-9 Diagnosis    Not medically necessary for all diagnoses
HCPCS No code   
ICD-10-CM (effective 10/01/14)    Not medically necessary for all diagnoses
   H16.001-H16.9 Keratitis code range
   H17.00-H17.9 Corneal scars and opacities code range
   H18.001-H18.9 Other disorders of cornea code range
ICD-10-PCS (effective 10/01/14)   ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this examination.
   08J0XZZ, 08J1XZZ Eye examination, code by body part (right eye or left eye)
Type of Service  Ophthalmology 
Place of Service  Physician’s Office 

 


 

Index

Corneal topography
Keratometry
Keratoscopy
Photokeratoscopy
Topography, corneal

 


 

Policy History

Date Action Reason
11/1/97 Add to Vision section New policy
7/12/02 Replace policy Policy reviewed without literature review; new review date only
10/09/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled
10/10/2006 Replace policy Policy updated with literature review.  Policy statement revised.
12/13/07 Replace Policy Policy updated with literature review; reference 3 added; policy statement unchanged.
04/24/09 Replace policy  Policy updated with literature review through January 2009; policy statement changed to not medically necessary. 
04/08/10 Replace policy Policy updated with literature review through February 2010; reference 3 added; policy statement unchanged
4/14/11 Replace policy Policy updated with literature review through February 2011; policy statement unchanged
04/12/12 Replace policy Policy updated with literature review through February 2012; policy statement unchanged
04/11/13 Replace policy Policy updated with literature review through March 13, 2013; reference 4 added; policy statement unchanged