Coding Q&A

New RAC verteporfin audits are being challenged


New RAC Verteporfin Audits Are Being Challenged


A rash of recent RAC (Recovery Audit Contractor) audits are now being seriously questioned on the grounds that a mandated test for the use of PDT is outdated.

The audits are being conducted based on the NCD (National Coverage Determination) 80.3.1 that mandates a fluorescein angiography be performed within 30 days prior to what CMS terms OPT (ophthalmic photodynamic therapy). Medicare uses the term OPT rather than PDT to differentiate between the use in ophthalmology and dermatology.

In early May of this year, CGI Federal, Inc., a RAC auditor, began initiating data-mining audits specifying return of the supply money for OPT (PDT) if the above NCD was not followed. CGI Federal has been sending out letters to providers requesting medical records for cases selected by this data-mining process.


This issue has come to the attention of the AAO, which has conferred with CMS and CGI Federal, expressing its position that these audits are based on an outdated NCD. The request for its rescission, has been posted on the CMS Web site. The following comes from that Web site:

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“The Centers for Medicare & Medicaid Services (CMS) on May 25, 2012, received a formal written request from the American Academy of Ophthalmology for review and rescission of NCD 80.3.1. The requestors note that the current coverage decision for OPT is from 2004, prior to the emergence of targeted anti-VEGF intravitreal treatments. The requestors say these newer therapies have largely supplanted OPT as initial management of AMD, and that OPT is largely relegated to patients in whom the newer therapies have failed. The requestors believe that the current NCD requirement for followup fluorescein angiography with OPT is not supportable for these ‘end-stage’ patients.”


► The initial letter is entitled “Review Notification Letter.” It outlines the process and gives instructions on submitting documentation. It is accompanied by a page entitled “Review Findings.” Essentially, that page explains the basis of the review and is a request for records.

Copies of the specified patient(s) charts should be enclosed as well as a chronology and additional supporting material.

► Subsequently, you will receive a determination letter (“Review Results”) that specifies either “No Findings” or “Overpayment.” If you receive the former, obviously nothing further needs to be done. If you get an “Overpayment” determination, further steps available would be to send in supplementary, supporting material. You can also request what is called a “Discussion.”
► If you do not succeed at this level, the matter will be turned over to the Medicare Administrative Contractor, who will send a Demand letter that identifies the final overpayment amount and outlines repayment options as well as legal rights.

Unfortunately, the comment period for support of the rescission has ended. However, CMS is receptive to public comment and you should write in support of the rescission. This is not a comment on the value of the treatment but rather a comment on the unnecessary performance of a fluorescein angiogram within 30 days prior to OPT since OCT, a noninvasive diagnostic test, has supplanted OPT in following these types of patients.


I urge all retina specialists to be proactive in what is happening in your field. It is important to bring issues to the attention of the organizations that represent you in order to avoid situations such as this. It is equally important to comment on these issues. RP
CPT codes copyrighted 2012 by the American Medical Association.