Article Date: 5/1/2006

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