Corneal Pachymetry (CPB 0681, reviewed 2025-10-15)

By October 15, 2025: Billing team must update claim submission protocols to require documented medical necessity verification for CPT 76514 (corneal pachymetry). Create a checklist in the billing system requiring claims to match one of the covered indications: anatomical narrow angles, bullous keratopathy, corneal edema, corneal refractive surgery (pre/post-op with refractive surgery plan coverage), corneal transplant (pre/post-op), complications evaluation, rejection evaluation, Fuchs' dystrophy, post-laser iridotomy status, glaucoma/glaucoma suspects (once per lifetime only), or posterior polymorphous dystrophy. Implement frequency limits: repeat testing for corneal diseases/injuries limited to once every 6 months maximum. DENY all claims for: (1) refractive surgery evaluation on plans excluding refractive surgery coverage; (2) screening asymptomatic patients without glaucoma signs/symptoms; (3) EndoART implant assessment; (4) cataract pre-op without documented corneal disease. Flag any claims with diagnoses from the non-covered list (keratoconus, Marfan syndrome, Terrien's degeneration, pterygium management, hydroxychloroquine monitoring) for automatic denial. Update encounter templates to capture specific indication and frequency of prior pachymetry tests. Consequences: Claims submitted without proper medical necessity documentation will be denied, resulting in revenue loss and potential compliance issues.