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CODING Q&A

What’s New for 2017?

Once again this year we see coding and reimbursement changes.

Q What CPT coding changes are slated for 2017?

A There are a number of changes pertinent to retinal specialists, including one new Category I CPT code. In our consulting practice, we don’t see this combination frequently, but it does happen.

  • 92242 Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral

The descriptions of these codes changed.

  • 67101 Repair of retinal detachment, 1 or more sessions including drainage of subretinal fluid when performed; cryotherapy
  • 67105 Repair of retinal detachment, 1 or more sessions including drainage of subretinal fluid, when performed; photocoagulation
  • 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
  • 92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

CPT 67101 and 67105 include minor changes to the description, and there are also changes to the global surgery period for these codes. The changes to 92235 and 92240 are especially significant, because both codes have been defined as unilateral until now. Medicare and most other payers consider “unilateral or bilateral” to mean bill once whether one or both eyes are tested. See Table 1 for the financial impact of these changes.

Table 1. There are some significant changes pertinent to retina, especially to physician work RVUs:
67101 Repair detached retina cryotherapy -58%
67105 Repair detached retina photocoagulation -59%
67107 Repair detached retina scleral buckle +12%
67110 Repair detached retina pneumatic retinopexy +16%
92235 Fluorescein angiography -22%
92240 ICG angiography -18%

A number of new Category III codes were to become effective January 1. These are pertinent to retina.

  • 0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
  • 0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
  • 0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)
    (To report intravitreal injection/implantation, see 67025, 67027, or 67028)

Be advised that coverage and payment for Category III codes remain at the discretion of the Medicare Administrative Contractor (MAC).

Q What is slated to happen with the Medicare Physician Fee Schedule as of January 1?

A The 2017 conversion factor is $35.8887, which is a slight increase from the 2016 conversion factor of $35.8043. It includes a budget neutrality adjustment of -0.013%, an increase of 0.5% resulting from MACRA, and a misvalued code reduction target adjustment of -0.18%. Relative Value Unit (RVU) changes also are expected to occur on Jan. 1.

The net result of all these changes is approximately a 2% reimbursement reduction for ophthalmology services overall. Some retina procedure codes were revalued to the RUCs original recommended RVUs after taking significant reductions in 2016.

In addition, the global surgery period for 67101 and 67105 will change from 90 days to 10 days. As with PRP (67228) last year, this adds to the financial impact for the Medicare fee schedule. We also note that the new combination angiography code (92242) has a greater value than either component (92235 and 92240) but much less than the combined values of these codes in 2016.

Q Are there changes for ASCs and HOPDs?

A Yes, there are small increases in facility reimbursement in 2017 for most codes. For ambulatory surgery centers, the wage adjustment for budget neutrality, in addition to the multifactor productivity adjusted update factor, increases the ASC conversion factor by 1.9% overall for those meeting the quality reporting requirements.

Various adjustments to hospital reimbursements result in an overall hospital outpatient department (HOPD) rate increase of 1.65%.

As with professional fees, there are a few big winners and losers for retina surgery facility fees. And, due to the differences between how ASC and HOPD fees are set, the changes are not always of the same magnitude or go in the same direction (Table 2).

Table 2. ASC and HOPD changes
ASC HOPD
67027 Implant intravitreal drug system - 31% + 28%
67036 Mechanical vitrectomy, pars plana + 79% + 96%
67041 Vitrectomy for macular pucker + 79% + 96%
67101 Repair detached retina cryotherapy - 57% + 5%
67105 Repair detached retina photocoagulation - 31% + 7%
67115 Release encircling material + 79% + 96%

Q There were many ICD-10 changes; did they transition well?

A The October 1, 2015, ICD-10 transition was relatively smooth. Unfortunately, the first major update of ICD-10 codes on October 1, 2016, has not gone as well as the original implementation in 2015. The update included 1,974 new codes, 311 deleted codes, and 425 revised codes. There were major updates for diabetic eye diseases and AMD.

Some Medicare contractors and other payers were tardy in updating local policies and edits or did so incorrectly. Hopefully most issues have been resolved by now. See October’s Coding Q&A column for more discussion about the changes. http://tinyurl.com/hxlvmmm

Q We’ve heard about new telehealth codes. What can you tell us?

A As telehealth continues to evolve in healthcare, so do coding changes to designate such services. Effective January 1, 2017, a new place of service code, POS 02 – Telehealth – is slated to become effective. Described as: The location where health services and health related services are provided or received, through telecommunication technology,” it is used by the physician or practitioner furnishing telehealth services from a remote site.

In the same CMS instruction document on the new POS, it reminds providers that one of two modifiers is required when billing Medicare for telehealth services.

  • GT – via interactive audio and video telecommunications systems
  • GQ – via an asynchronous telecommunications system

For CPT 2017, a new telehealth modifier is being added.

  • 95 – Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

Unfortunately, this modifier may only be appended to a specific list of CPT codes for services typically performed face-to-face but may be rendered via real-time (synchronous) interactive audio and video telecommunications system. Find the codes in Appendix P of the 2017 CPT Manual.

They include evaluation and management (E/M) codes and two remote imaging codes, 92227 (Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision) and 92228 (Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral). CPT 92250 (Fundus photography, with interpretation and report) is not included on the list of approved codes for telehealth.

It is important to remember that any telehealth service must be live and interactive for Medicare coverage. This limits its applicability, at least for now.

Other payers, however, may be more amenable. RP