Coverage Policy Manual
Policy #: 2007003
Category: Medicine
Initiated: February 2007
Last Review: July 2018
  Corneal Topography

Description:
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. For example, computer-based programs can combine with keratoscopy to create graphic displays and high-resolution color-coded maps of the corneal surface.
 
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.
 
Coding
This procedure was previously not separately reportable, and past coding conventions recommended this service be included as part of a general ophthalmological service or reported with unlisted ophthalmological service or procedure code 92499.
 
A new code for the computerized study, 92025, was established and became effective 1/1/07.  (92025 is not used for manual keratoscopy, which is part of a single system Evaluation and Management or ophthalmological service)
 
Computerized corneal topography is not separately reportable with keratoplasty procedures described by CPT codes 65710, 65730, 65750, and 65755.
 
 

Policy/
Coverage:
Effective July 2018
Computerized corneal topography meets primary coverage criteria for effectiveness and is covered in the following instances:
    • To determine intraocular lens power prior to cataract surgery in patients with an irregular corneal curvature when that determination cannot be made with conventional keratometer readings combined with an A-scan reading. Limited to one unit of service per eye per lifetime.
    • To evaluate irregular astigmatism after cataract, glaucoma, pterygium, pseudopterygium, penetrating or lamellar keratoplasty surgery. Limited to one unit of service per eye per year.
    • To evaluate a patient with corneal abnormalities in which fitting of a therapeutic contact lens for either vision enhancement or pain relief is impossible with conventional techniques. Limited to one unit of service per eye per year.
    • To evaluate a patient who has a significant change in the refractive status of the eye in whom keratoconus or other corneal disease is suspected.  
 
Computerized corneal topography is not covered if used as part of an examination to determine the necessity of, or to follow-up, procedures excluded or with limited coverage in the member benefit contract, including, but not limited to: the provision of eyeglasses and cosmetic contact lenses; intraocular lenses, refractive keratoplasty, epikeratophakia procedures and Laser Assisted Insitu Keratomileusis (LASIK).
 
Computerized corneal topography is not covered, preoperatively or postoperatively, for lens replacement for the purpose of changing the refractive error of the eye unless there was injury to the cornea from trauma or disease.
 
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.
 
Effective Prior to July 2018
Computerized corneal topography meets primary coverage criteria for effectiveness and is covered in the following instances:
    • To determine intraocular lens power prior to cataract surgery in patients with an irregular corneal curvature when that determination cannot be made with conventional keratometer readings combined with an A-scan reading. Limited to one unit of service per eye per lifetime.
    • To evaluate irregular astigmatism after cataract, glaucoma, pterygium, pseudopterygium, penetrating or lamellar keratoplasty surgery. Limited to one unit of service per eye per year.
    • To evaluate a patient with corneal abnormalities in which fitting of a therapeutic contact lens for either vision enhancement or pain relief is impossible with conventional techniques. Limited to one unit of service per eye per year.
 
Computerized corneal topography is not covered if used as part of an examination to determine the necessity of, or to follow-up, procedures excluded or with limited coverage in the member benefit contract, including, but not limited to: the provision of eyeglasses and cosmetic contact lenses; intraocular lenses, refractive keratoplasty, epikeratophakia procedures and Laser Assisted Insitu Keratomileusis (LASIK).
 
Computerized corneal topography is not covered, preoperatively or postoperatively, for lens replacement for the purpose of changing the refractive error of the eye unless there was injury to the cornea from trauma or disease.
 
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.

Rationale:
Assessing corneal topography has been done for many years and is a part of the standard ophthalmologic examination of some patients. However, there are multiple ways to evaluate/determine corneal topography.
 
The American Academy of Ophthalmology has petitioned for an explicit CPT code for corneal topography on several occasions. Previously, the CPT committee considered the procedure as part of the evaluation and management level of service or part of the general ophthalmology examination and no explicit CPT code was issued for corneal topography despite its use in practice until January 1, 2007.
 
2010 Update
A search of the Medline database through February 2010 did not identify any published literature that would prompt a change in the coverage statement.  
 
2012 Update
A literature search was conducted using the MEDLINE database through May 2012. There was no new literature that would prompt a change in the coverage statement.
  
2013 Update:
AAO guidelines updated July 2013 state:  A comprehensive medical eye evaluation should be performed before any refractive surgery procedure.  Visual acuity determination and refraction require particular attention.  Computerized corneal topography is important to assess the optical state of the cornea. It is also relevant if a keratorefractive surgical procedure is necessary to optimize the refractive result after the lens surgery or for toric IOL implantation.
 
Recommendation:
Before refractive surgery, corneal topography should be evaluated for evidence of irregular astigmatism, corneal warpage, or abnormalities suggestive of keratoconus or other corneal ectasias. All of these conditions may be associated with unpredictable refractive outcomes, and keratoconus and the ectasias with ectasia progression following keratorefractive surgery.  When considering intraocular refractive surgery, measurement of corneal topography is important to assess the optical characteristics of the cornea.  It is also relevant if a keratorefractive surgical procedure is necessary to optimize the refractive result after the lens surgery or for toric intraocular lens implantation. (strong recommendation, moderate evidence)
 
2014 Update
 
A literature search conducted through June 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
2015 Update
 
A literature search was conducted through December 2014. There was no new literature identified that would prompt a change in the coverage statement.
 
Aggarwar et al. (2014) published the results of a study on the evidence of association between HLA-B1502 and anticonvulsant induced Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) from the Indian population. Patients with a history of SJS/TEN secondary to carbamazepine or phenytoin were enrolled. The control group comprised of patients who had received carbamazepine/phenytoin for 6months without any adverse cutaneous event. Low-resolution DNA typing for HLA-B and high resolution HLA-B15 typing was performed. Seventeen patients with history of SJS/TEN secondary to carbamazepine (9) or phenytoin (8) and 50 tolerant controls (carbamazepine-37; phenytoin-13) were enrolled. HLA-B1502 was observed in 2/9 (22.2%) carbamazepine-SJS/TEN patients and none of the 37 carbamazepine tolerant controls (p=0.035). HLA-B1502 was not observed in any of the 8 phenytoin-SJS/TEN patients or the 13 phenytoin tolerant controls. The data suggested that HLA-B1502 is a risk factor for carbamazepine induced SJS/TEN. Therefore, HLA-B1502 testing should be performed prior to initiating carbamazepine in North Indian population.
 
 
Tangamornsuksan et al. published the results of a comprehensive search done to determine the relationship between the HLA-B*1502 allele and carbamazepine-induced and carbamazepine-induced SJS and TEN.  The search yielded 525 articles, of which 16 met the inclusion criteria. The studies included 227 SJS or TEN cases, 602 matched control subjects, and 2949 population control subjects.  The summary odd ratio (OR) for the relationship between HLA-B*1502 and carbamazepine-induced SJS and TEN was 79.84 (95% CI, 28.45-224.06). Racial/ethnic subgroup analyses yielded similar findings for Han-Chinese (115.32; 18.17-732.13), Thais (54.43; 16.28-181.96), and Malaysians (221.00; 3.85-12 694.65). Among individuals of white or Japanese race/ethnicity, no patients with SJS or TEN were carriers of the HLA-B*1502 allele.  The authors concluded that a strong relationship between the HLA-B*1502 allele and carbamazepine-induced SJS and TEN in Han-Chinese, Thai, and Malaysian populations. HLA-B*1502 screening in patients requiring carbamazepine therapy is warranted.
 
2016 Update
A literature search was conducted through December 2015. There was no new literature identified that would prompt a change in the coverage statement.
 
2017 Update
A literature search conducted through June 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
CONTACT LENS FITTING
In 2017 Weber and colleagues reported on a prospective, observational study of the association between computer-assisted corneal topography measurements (Pentacam) and scleral contact lens fit (Weber, 2016). The study included 47 patients (63 eyes) with a variety of indications for scleral contact lenses, most commonly (n=24 eyes) keratoconus. Pentacam measurements were correlated with a subset of the scleral contact lens parameters (corneal astigmatism, anterior chamber depth, and corneal height; P<0.001, not adjusted for multiple comparisons) for the group as a whole.
 
2018 Update
Fernández Pérez (2014) published an article on early diagnosis of keratoconus and how newer technologies such as corneal topography can assist in the diagnosis and progression of keratoconus.  Corneal topography is capable of identifying subtle presentations of corneal ectasia.  In corneal refractive surgery, early diagnosis of keratoconus (subclinical asymptomatic keratoconus) is of great importance in patients seeking surgery because it can prevent progression of the pathology after surgery and make it symptomatic (corneal ectasia).  There is a need for diagnostic tests that provide high sensitivity (ability to detect the disease in affected subjects) with the objective that no asymptomatic subclinical keratoconus ends up not being diagnosed and thus not undergo corneal refractive surgery.
 
Sedghipour et al (2012) also published an article that reviewed corneal topography and use of the KISA% index in diagnosing keratoconus.  This study compared the sensitivity and specificity of the KISA% index with the keratometry (K) value, inferior-superior (I-S) value, relative skewing of the steepest radial axes (SRAX), and keratometric astigmatism (AST) indices in 25 patients presenting with bilateral keratoconus. The authors concluded that the keratoconus percentage index (KISA%) was significantly more sensitive and specific than the other indices examined. Furthermore, it was significantly better at predicting positive and negative results than the other indices included in the study.
 
Martinez-Abad et al (2017) sought to determine whether 3 vector parameters--ocular residual astigmatism (ORA), topography disparity (TD), and corneal topographic astigmatism (anterior and total--could serve to detect clinical and subclinical keratoconus. One hundred sixty-one eyes were studied in this retrospective comparative study; 61 eyes (38 patients) with keratoconus; 19 eyes (16 patients) with subclinical keratoconus; and a control group of 100 healthy eyes. All study participants underwent a thorough eye exam; further, software was used (iASSORT) to calculate ORA, TD, and corneal topographic astigmatism. Using a receiver operating characteristic curve analysis, the diagnostic capabilities of the 3 parameters were measured; to further assess diagnostic ability, a cutoff was determined that correlated to the highest sensitivity and specificity of the curve. Results showed that ORA and TD had good diagnostic capability to detect keratoconus (ORA: cutoff, 1.255 diopters [D]; sensitivity: 82%; specificity: 92%; TD: cutoff, 1.035 D; sensitivity, 78.5%; specificity, 86%). corneal topographic astigmatism did not show potential as a diagnostic tool. The authors concluded that TD and ORA were beneficial tools for detecting subclinical keratoconus.
 
DeNaeyer et al (2017) investigated the use of the sMap3D system (Precision Ocular Metrology), which measures the surface of the eye for patients in need of a scleral contact lens fitting.The sMap3D captures a series of images to produce a single wide field topographic “stitched” image of all captured images. To create these images, the patient is asked to provide several “gazes” (gaze up, gaze down, gaze straight). Twenty-five eyes (from 23 patients) were examined using the sMap3D. The “stitched” image produced by the sMap3D was then compared with the single captured straight-gaze image. At a diameter of 10 mm from the corneal center, both straight-gaze image and the sMap3D stitched image displayed 100% coverage of the eye. However, at 14 mm, the straight-gaze image only mapped 68% of the eye; at 15 mm, 53%; at 16 mm, 39%, and at 20 mm, 6%. For the stitched image produced by sMap3D: at 14 mm, 98% coverage; at 15 mm, 96% coverage; at 16 mm, 93% coverage; and at 20 mm, 32% coverage. While there was a significant drop off in coverage between 16 mm and 20 mm for the sMap3D image, the stitched image was considerably more accurate than the straight-gaze image.
 
Bandlitz et al (2017) studied the profile of the limbal sclera in 8 meridians by using spectral domain optical coherence tomography and a confocal scanning laser ophthalmoscope. The objective of this study was to evaluate the relation between central corneal radii, corneal eccentricity, and scleral radii improve soft and scleral contact lenses. The limbal scleral radii of 30 subjects were measured. Eight meridians, each 45° apart, were scanned, and it was determined that corneal eccentricity and scleral radii did not correlate in any of the meridians. The authors concluded that the independence between meridians might prove useful in fitting soft and scleral contact lenses.
 
De Sanctis et al (2017) reported on corneal astigmatism in patients seeking toric IOL implantation. The authors compared 2 methods for measuring corneal astigmatism: (1) corneal astigmatism total corneal refractive power (CATCRP), which uses a ray-tracing method that sends light through the cornea; and (2) corneal astigmatism simulated keratometry (CASimK), which is a surface-based exterior measurement that measures the steep radius of the anterior cornea. Both methods relied on the camera system (Pentacam HR) to calculate vector differences. Of 200 patients, 77 individuals (60 eyes) remained for IOL implantation. For a patient to qualify for toric IOL implantation, corneal astigmatism had to be greater than 1 D. Using corneal astigmatism total corneal refractive power CATCRP, 17 eyes were found with greater than 1 D; using CASimK, 13 eyes were found with greater than 1 D. However, of the 77 IOL implantation candidates, the CASimK method assessed 17 patients to have corneal astigmatism less than or equal to 1 D. Moreover, the CASimK method found 13 of 123 patients who were not candidates for implantation to have astigmatism greater than 1 D. This difference suggested potential issues with patient selection criteria.

CPT/HCPCS:
92025Computerized corneal topography, unilateral or bilateral, with interpretation and report

References: Aggarwar R, Sharma M, Modi M, et al.(2014) HLA-B*1502 is associated with carbamazepine induced Stevens-Johnson syndrome in North Indian population. Hum Immunol. 2014 Oct 8;75(11):1120-1122. PMID: 25305458.

American Academy of Ophthalmology(2013) Refractive Errors & Refractive Surgery PPP - Updated July 2013 Available online at http://one.aao.org

American Academy of Ophthalmology. Corneal topography. Ophthalmology, 1999; 106:1628-38.

Bandlitz S, Baumer J, Conrad U, et al(2017) Scleral topography analysed by optical coherence tomography Cont Lens Anterior Eye Aug 2017;40(4):242-247 PMID 28495356

de Sanctis U, Donna P, Penna RR, et al(2017) Corneal astigmatism measurement by ray tracing versus anterior surface-based keratometry in candidates for toric intraocular lens implantation Am J Ophthalmol May 2017;177:1-8 PMID 28185842

DeNaeyer G, Sanders DR, Farajian TS(2017) Surface coverage with single vs multiple gaze surface topography to fit scleral lenses. Cont Lens Anterior Eye Jun 2017;40(3):162-169 PMID 28336224

Fernández Pérez J, Valero Marcos A, Martínez Peña FJ(2014) Early diagnosis of keratoconus: what difference is it making? Br J Ophthalmol. 2014 Nov;98(11):1465-6 doi: 101136/bjophthalmol-2014-305120 Epub 2014 Apr 23

Karabatsas CH, Cook SD, et al.(1998) Surgical control of late postkeratoplasty astigmatism with or without the use of computerized video keratography: a prospective, randomized study. Ophthalmology, 1998;105:1999-2006.

Lembach RG.(2003) Use of contact lenses for management of keratoconus. Ophthalmology Clin North Am, 2003; 16:383-94, vi.

Martinez-Abad A, Pinero DP, Ruiz-Fortes P, et al(2017) Evaluation of the diagnostic ability of vector parameters characterizing the corneal astigmatism and regularity in clinical and subclinical keratoconus Cont Lens Anterior Eye Apr 2017;40(2):88-96 PMID 27931882

Morrow GL, Stein RM.(1992) Evaluation of corneal topography: past, present and future trends. Can J Ophthalmol, 1992; 27:213-25.

Sedghipour MR, Sadigh AL, Motlagh BF(2012) Revisiting corneal topography for the diagnosis of keratoconus: use of Rabinowitz's KISA% index Clin Ophthalmol.  2012;6:181-4 doi: 10. 2147/OPTH. S24219. Epub 2012 Jan 26. PMID: 22331975

Szczotka LB.(2003) Corneal topography and contact lenses. Ophthalmol Clin N Am, 2003; 16:433-53.

Tangamornsuksan W, Chaiyakunapruk N, Somkrua R, et al.(2013) Relationship between the HLA-B*1502 allele and carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis. JAMA Dermatol. 2013 Sep;149(9):1025-32. PMID: 23884208.

Weber SL, Ambrosio R, Jr., Lipener C, et al.(2016) The use of ocular anatomical measurements using a rotating Scheimpflug camera to assist in the Esclera(R) scleral contact lens fitting process. Cont Lens Anterior Eye. Apr 2016;39(2):148-153. PMID 26474924

Wilson SE, Klyce SD.(1991) Advances in the analysis of corneal topography. Surv Ophathalmol, 1991; 35:269-77.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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