CODING Q &
A
A Simple Guide to Coding AMD Treatments
ANSWERS PROVIDED BY RIVA LEE ASBELL
Q. Can you provide me with a simple grid for
coding for new technology pharmacotherapy AMD treatments?
A.
Here you go!
CPT CODING BY TREATMENT DELIVERY
SYSTEM
|
Type
of Service |
How
to Code (CPT Code) |
Notes |
|
Intraocular Injections |
67028 Intravitreal injection of pharmacologic
agent |
If
an off-label use, be sure to have this in your informed consent and check your Medicare
carrier's LCD (Local Coverage Determination) for Off-Label Use of FDA-Approved Non
Oncologic Drugs Conditions |
|
Implantation
of an intravitreal drug delivery system such as Retisert |
67027 Implantation of intravitreal
drug-delivery system (eg, ganciclovir implant), included concomitant removal of
vitreous |
Use modifier 59 to unbundle 67036 (pars plana vitrectomy) if complete
vitrectomy is performed — this is not for incidental removal of vitreous that
normally accompanies this type of surgery |
|
Ocular
Photodynamic Therapy |
67221 Destruction of localized lesion of choroids (eg, choroidal
neovascularization); photodynamic therapy (includes intravenous infusion)
67255
photodynamic therapy, second eye, at single session |
67255 is an add-on code and should
not be billed using modifier 51 |
|
Topical
Therapy |
E/M or Eye
Codes |
Included in the office visit or consultation |
|
Systemic
Therapy |
E/M or Eye
Codes |
Included in the office visit or consultation |
|
Posterior
Juxtascleral Depot |
0124T Conjunctival incision with posterior juxtascleral placement
of pharmacological agent (does not include supply of medication) |
This is a Category
III code released July 1, 2005 for implementation Jan. 1, 2006. Medicare will not
pay for this until FDA approval of the drug occurs, and then it is a local carrier
decision, as is true for all Category III codes. |
Q.
How do I code for combination therapies such as Ocular Photodynamic Therapy (OPT)
and Macugen intravitreal injection when performed on the same day?
A. Sometimes different therapies are combined on the same day
such as CPT code 67028 (Intravitreal injection) + CPT code 67221 (OPT). In this
example both procedures have "0" days global period. Multiple-surgery rules apply
— you will be paid at 100% of OPT (6.01 RVUs) and 50% of the injection (4.10
RVUs). The math: payment on a national average is: $227.76 + $77.69 = $305.45. However,
there is no multiple-surgery rule reduction for the second procedure if the procedures
are performed on separate days. An appropriate modifier must be used when another
procedure is performed within the global period of the first procedure, which may
result in reduced payment. Modifier usage is not necessary if the global period
is "0" days.
Q. Can we bill an office visit the same day as the Macugen injection?
Our doctors are looking in the eye to determine whether or not the Macugen is working
and to be sure that there is no other reason why they should not inject. The chart
notes from the previous visit state that the plan is "possible Macugen injection".
A. For Medicare, if there is not a separately identifiable service
then the office visit and a procedure cannot be charged on the same day. If the
documented plan states the patient is to return for any procedure, be it a Macugen
injection, further laser treatment, YAG capsulotomy or chalazion excision, then
the office visit would not be billable unless the patient presented with a different
problem or new symptoms.
A good policy for Macugen injections, now in draft form, that
clarifies this policy can be found at
www.EmpireMedicare.com under Local Coverage
Determinations.
Riva Lee
Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement
firm in Philadelphia. She can be reached through her Web site at
www.RivaLeeAsbell.com.
Retinal Physician, Issue: May 2006