Coding Correctly for Intravitreal Injections
ANSWERS PROVIDED BY RIVA LEE ASBELL
Q. I have run into coding problems when I want
to code using both CPT codes 67028 (intravitreal injection) and 67025 (injection
of vitreous substitute) when both are performed at the same session. They are bundled
in the Correct Coding Initiative. Can I unbundle them? Code 67028 has a 0 day global
and 67025 has a 90-day global. Can I choose which code I want – if I ignore
67025 I will be able to bill for my office visits and make out better?
A. Do not selectively eliminate codes when listing multiple codes
just to obtain higher reimbursement.
For example, if both CPT codes 67028 (Intravitreal injection of
a pharmacological agent) (0 global) (4.08 RVUs) and 67015 (Aspiration or release
of vitreous, subretinal or choroidal fluid, pars plana approach [posterior sclerotomy])
(90 global) (13.39 RVUs) are performed on the same day, you cannot ignore 67015
just to be able to capture the 0 day global period and bill for the postoperative
visits. Use the NCCI bundles and list the comprehensive code for payment.
Q. Since Lucentis has been approved, will my Medicare carrier
pay for both Lucentis and Avastin injections? What about the supply?
A. Unless you are instructed otherwise, your carrier will pay
for Lucentis injections and the supply. The various Medicare carriers are posting
specific instructions on how to bill properly. However, there may be some problem
processing the claims at this time because the supply does not yet have
code and the claims will have to be processed manually.
J codes 3490 and 3590 are unclassified codes. The carriers have to get into gear
which may take a month or even longer.
Avastin injections present a more complicated problem. Some carriers
are considering the injection and supply as noncovered, whereas others are covering
If your carrier is covering the injection and supply, follow the
instructions and you should not have a problem getting paid.
For those carriers that do not have announced coverage, continue
to consider the injection and the supply as investigational and proceed on the assumption
that the patient has to pay for both. Continue to use an informed consent that specifies
that this is an off-label use and describes the risks involved.
There is no reason that your Medicare carrier will not pay for
both Lucentis and Avastin injections (when Avastin injection is a covered service).
Q. The recently released results of Bascom Palmer's PrONTO study
recommend that the timing of intravitreal injections of Lucentis be gauged by findings
on OCT. Are there any pitfalls to watch out for? Will I be paid for all the OCTs
that need to be performed?
A. Getting reimbursed for the OCTs can be a little tricky because
there are so many variables involved and they differ from Medicare carrier to Medicare
The CPT code used for OCT is 92135 – Scanning computerized
ophthalmic diagnostic imaging. Not all carriers have incorporated retinal diagnoses
into their policies/computers. If your carrier has not incorporated the retinal
diagnosis (in this case 362.52) into the LCD (local coverage determination), then
you must use CPT code 92499 (Unlisted ophthalmological service or procedure). You
may have to deal directly with your carrier or Carrier Advisory Committee (CAC)
in order to resolve the processing of these claims.
If your carrier has incorporated the retinal diagnoses into its
LCD policy, then you most likely will not have a problem getting paid for the first
2 or 3 OCT tests. You may run into a problem because the CPT code 92135 is also
used for glaucoma testing and there are limits on the utilization of those codes
with that diagnosis.
Negotiations with your carrier or through your CAC may be helpful
in getting all of the OCT tests paid if there is a problem.
If your carrier informs you (always in writing) that more than
a given number will not be paid in a given time frame due to lack of medical necessity,
then the patient can be billed for the test.
When billing the patient, be sure to get a signed ABN (advanced
beneficiary notice) that specifies the reason for the test.
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: September 2006