Coding Q&A

Which Retina Procedures Should Be Performed in an ASC?


Which Retina Procedures Should Be Performed in an ASC?


Q. Which retina procedures can best be performed and reimbursed in an ambulatory surgery center (ASC) setting? We recently received our certificate of need for our ASC and will be looking to develop a list of procedures that will be performed in this facility

A. This is a critical question for 2008 because Medicare has changed the entire Ambulatory Surgery Center (ASC) payment methodology and many ASCs are looking to incorporate retinal procedures.

One of the main differences between the old and new systems is that the old system was inclusionary whereas the new system's list is exclusionary. The inclusionary list enumerated the procedures that could be paid to the facility. If a given procedure (such as one with a new CPT code) was not on the list, then the facility could not bill for it until such time as it was added to the list. Furthermore, the patient could not be billed since it was a covered procedure.

The new system assumes all procedures with a CPT code — this includes Category I, II and III codes, are included unless there is too great a risk to the patient to be performed on an outpatient basis. The list is to be updated quarterly. There is currently only 1 exclusion — CPT Code 65273 (Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization).

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

The list is found in the Federal Register in the final rules of OPPS (Outpatient Prospective Payment System — Nov. 27, 2007) and ASC's. You can purchase the Federal Register from the Government Printing Offices (202-512-1800). Physicians fee schedule is Volume I and ASC is Volume II. It is also available online at

More will be written about retinal ASC reimbursement in future issues, but here is a warning — give serious consideration before deciding to move all your office-based procedures, such an intravitreal injections, to the ASC for convenience. The surgeon will receive less financial reimbursement compared to the procedure being performed in the office. Medicare is trying to avoid migration of procedures to the ASC. Thus, the financial penalties for doing so.

Q. With an ever-increasing volume of patients requiring intravitreal injections, we are considering doing our injections at an adjacent ASC. We do not own it but our physicians operate there and are investors.

We are considering doing an "injection day" in the ASC, which we feel will be more controlled as opposed to a hectic clinic setting, better prep to help decrease the risk of endophthalmitis and the ability to perform AC paracentesis ("AC tap") under the scope to reduce the risk of elevated IOP. I would appreciate any thoughts of this matter with regards to practicality, coding, and reimbursement issues, Medicare concerns, etc. The way I see it, the MD would bill for the injection as usual and the ASC would bill for the AC tap.

A. With the new ASC payment reform, many physicians are considering performing intravitreal injections in the ASC rather than in the office. Under the new system, this procedure (CPT code 67028) is considered originally office-based. Thus, the reimbursement for the physician is lower when performed in the ASC. For Empire Medicare, as an example:, if performed in the office the reimbursement is $207.49 and if performed in the ASC (a facility), it is $157.10.

When procedures are performed in an ASC, there is a fee schedule for the reimbursement to the facility. Physicians have a different fee schedule with differentiation in payment for some procedures when they are performed in the office vs performed in the facility. So you can "bill for the injection as usual" but your payment is based on where the procedure was performed.

The paracentesis has a physician reimbursement of $145.84 when performed in the office and $122.51 when performed in the ASC (Empire Medicare).

CPT codes copyright 2006 American Medical Association. RP