How To Use HCPCS Code G9520

HCPCS code G9520 describes a specific situation where a patient does not achieve the final refraction (spherical equivalent) within a certain range of their planned refraction within 90 days of surgery. This code is used to indicate that the patient’s post-surgical refractive outcome did not meet the expected outcome.

1. What is HCPCS G9520?

HCPCS code G9520 is a specific code used in medical coding to identify cases where a patient does not achieve the final refraction (spherical equivalent) within +/- 1.0 diopters of their planned refraction within 90 days of surgery. This code is used to document and track cases where the patient’s post-surgical refractive outcome did not meet the expected outcome.

2. Official Description

The official description of HCPCS code G9520 is “Patient does not achieve final refraction (spherical equivalent) +/- 1.0 diopters of their planned refraction within 90 days of surgery.” The short description for this code is “Refract not +/- 1.0 w/in 90d.”

3. Procedure

1. The provider should first assess the patient’s planned refraction, which is the expected outcome of the surgery.
2. After the surgery, the provider should perform a post-operative refraction to determine the patient’s actual refractive outcome.
3. If the patient’s post-operative refraction is not within +/- 1.0 diopters of the planned refraction, HCPCS code G9520 should be used to indicate this discrepancy.
4. The provider should document the specific details of the patient’s refractive outcome and the reasons for the deviation from the planned refraction.

4. When to use HCPCS code G9520

HCPCS code G9520 should be used when a patient does not achieve the final refraction (spherical equivalent) within +/- 1.0 diopters of their planned refraction within 90 days of surgery. This code is applicable in cases where the patient’s post-surgical refractive outcome deviates from the expected outcome by more than the specified range.

5. Billing Guidelines and Documentation Requirements

When using HCPCS code G9520, healthcare providers should ensure proper documentation of the patient’s planned refraction, post-operative refraction, and the deviation from the expected outcome. This documentation should include the specific measurements and calculations used to determine the patient’s refractive outcome. When billing for this service, providers should follow the standard billing guidelines and include the appropriate HCPCS code on the claim form.

6. Historical Information and Code Maintenance

HCPCS code G9520 was added to the Healthcare Common Procedure Coding System on January 01, 2016. As of January 01, 2020, there have been no maintenance actions taken for this code, as indicated by the action code N, which means no maintenance for this code. This code is used to track cases where the patient’s post-surgical refractive outcome does not meet the expected outcome within the specified range.

7. Medicare and Insurance Coverage

Medicare and other insurance providers may cover the use of HCPCS code G9520, but coverage may vary depending on the specific policies and guidelines of each insurance plan. The pricing indicator code for this code is 00, which indicates that the service is not separately priced by Part B. The multiple pricing indicator code is 9, which means that the value for pricing this code is not established. Providers should consult the Medicare and insurance coverage guidelines to determine the reimbursement and coverage details for this specific code.

8. Examples

Here are five examples of when HCPCS code G9520 should be billed:

1. A patient undergoes refractive surgery, but their post-operative refraction deviates by more than +/- 1.0 diopters from the planned refraction within 90 days.
2. Another patient undergoes cataract surgery with an expected refractive outcome, but their post-operative refraction falls outside the specified range within the designated time frame.
3. A third patient undergoes LASIK surgery, but their post-operative refraction does not align with the planned refraction within the specified range within 90 days.
4. In a fourth case, a patient undergoes corneal refractive surgery, but their post-operative refraction does not meet the expected outcome within the specified range within the designated time frame.
5. Lastly, a patient undergoes lens replacement surgery, but their post-operative refraction deviates from the planned refraction by more than +/- 1.0 diopters within 90 days.