Does 92136 require prior authorization?

No, 92136 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 92136?

Medicare facility rate: $48.10. Non-facility rate: $48.10. Work RVU: 0.53.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.53

Facility

$48.10

Non-Facility

$48.10

The medical record must document relevant medical history, physical examination, indications for testing, an order for testing, test results, and the IOL power calculation; records must include patient name and date of service and be available to Medicare on request.
For diagnostic tests, report the result of the test if known; if the result is not available, report the symptoms that prompted the performance of the test.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
When separate technical and professional components are reported, appropriate modifiers must be used (e.g., -TC for technical, -26 for professional) and the professional component must include the anatomic modifier (-RT or -LT) to indicate the eye.

Ophthalmic biometry (CPT 76519 or 92136) is covered for preoperative intraocular lens (IOL) power calculation for patients undergoing cataract surgery.
Use diagnostic ultrasound A-scan (76519) for routine/simple cataract cases when performing IOL power calculation.
Use ultrasound B-scan (as clinically indicated) for patients with dense cataract where A-scan is not adequate for IOL power calculation.
Additional biometric testing beyond one scan is covered when there is an additional diagnosis beyond cataract and the medical need for the additional tests is fully documented.
Ophthalmic biometry using CPT 76519 (A-scan) or CPT 92136 (optical coherence biometry) is payable under Medicare Part B when performed for intraocular lens (IOL) power calculation.
The global service (76519 or 92136 global) is payable in the office (place of service 11) and independent clinic (49).

L33621 — Ophthalmic Biometry for Intraocular Lens Power Calculation

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A56549 — Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation

J06

L33693 — Peripheral Venous Ultrasound

J09

A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)

J12

Ask Verity about documentation requirements, denial risks, or coverage in your state.