Reimbursement: Sorting Out the Confusion
PROVIDED BY RIVA LEE ASBELL
have had so many conflicting instructions on how I can bill for intravitreal injections
of ranibizumab (Avastin). Could you provide some clarifications?
A. For Medicare, this is still a work in progress and
the final determination is made by your local Medicare carrier. Not all carriers
have yet to tackle this. It is imperative that you get written directions from your
carrier's medical director or someone in authority at the policy level. This communication
may be via a special bulletin, in the news alert, or by personal written communication.
The answer varies from 1 Medicare carrier to the other.
However, most carriers are currently putting out notices that
both the procedure (CPT code 67028) and the supply (usually J3490 because the systemic
Avastin supply is not the correct dosage and is not what is actually used) are not
covered services based on the premise that the drug is considered investigational;
therefore, the method for delivery of that drug also must be considered investigational,
and thus not a benefit under the Medicare program.
I strongly urge you to read the policies on either Off-Label Use
of Drugs for Nononcologic Conditions (www.kansasmedicare.com) or Off-Label Coverage
of FDA Approved Drugs (www.empiremedicare.com). Understanding this concept will
help you in future management of use of off-label drugs and reimbursement issues.
Misunderstandings initially occured when some practices billed
for the procedure and the carriers did not realize the claim was for an investigational
drug and proceeded to pay it. Now, the carriers are beginning to issue instructions
to providers that these monies need to be voluntarily refunded.
At the same time, some carriers are issuing specific directions
that they are to be billed after the monies are collected from the patient, and
to append a GA modifier to the service. A good rule to follow with intravitreal
Avastin injections is that, with all carriers, the patient must pay up front for
the procedure and supply. Any reimbursement that is allowed under the specific carrier's
policies will then come later.
Be careful. If your carrier has not geared up to have these claims
rejected, you will be paid and will be in the uncomfortable position of having to
refund monies paid. Make sure you have instructions from your carrier to do this.
Different states under the same carrier may have different instructions.
Lastly, do not forget to have a proper informed consent signed.
One specifically for intravitreal injection of Avastin may be downloaded from the
OMIC website (www.omic.com).
Q. Could you please explain why I cannot perform intravitreal
injections in an ambulatory surgery center (ASC)? It is much easier for me to perform
the injection there and have the ASC deal with purchasing the drug and getting reimbursed
A. CPT procedure code 67028 (Intravitreal injection of pharmacologic
agent) is not on the list of procedures covered by Medicare in an ASC. Thus, it
becomes a noncovered service and the physician has to pay for it, not the patient.
A facility is prohibited from billing a patient for a procedure that is a covered
procedure for Medicare under ordinary circumstances, when it is performed in an
ASC. Therefore, the physician has to pay for the service and the supplies because
failure to do so may be construed as an inducement. This rule applies whether or
not the physician is an owner/part owner or is just using the facility.
Q. There was a conversation on a practice management list serve
dealing with the necessity of vitals (pulse, blood pressure, respiratory function)
prior to the performance of any procedure in any location. I did not see any final
word on this. Does anyone know if we do indeed need to measure this for a focal
laser or Macugen injection performed in the office?
A. The requirement for vital sign measurements does not apply
to procedures performed in the office setting. This is frequently confusing to billing
people who are given this information at seminars and do not realize that such requirements
pertain only to given sites of service.
CPT codes copyright 2005 American Medical Association.
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
Retinal Physician, Issue: March 2006