Ophthalmology and Optometry Coding Alert

With up to $2,191 at stake, knowing your payer's rules is critical.

Sticking to your carriers' preferred HCPCS code for reporting Lucentis, Avastin, and Macugen can net your practice from $50 to almost $2,200.

Earlier, Ophthalmology Coding Alert explained the use of 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) to report the drug injections ophthalmologists can use to treat age-related macular degeneration (AMD) ("Don't Let AMD Reimbursement Fade Away," Volume 12, Number 5). Here's how to keep AMD injection supply codes straight for three of the often-used drugs:

• bevacizumab (trade name Avastin)

• ranibizumab (trade name Lucentis)

• pegaptanib sodium (trade name Macugen).

Stick With J2778 for Lucentis

To treat AMD, patients may receive an average of five to seven 0.5 mg injections per year of Lucentis. This drug is an anti-vascular endothelial growth factor (VEGF) agent that controls the growth and leakage of abnormal new blood vessels, explains Becky Zellmer, CPC, COTA, MBS, CBCS, medical billing and coding supervisor for Suby, Von Haden and Associates in Neenah, Wis. The most effective anti-VEGF agent approved by the Food and Drug Administration (FDA), it's the first treatment to show an average improvement in visual acuity after one year of treatment in clinical studies, she notes.

Do this: In most cases, you'll report J2778 (Injection, ranibizumab, 0.1 mg) for Lucentis, says Zellmer, who presented a seminar on intravitreal injections at the Coding Institute's June conference. Append modifier LT (Left side) or RT (Right side) to the code to indicate which eye the ophthalmologist injected. For the indicated single Lucentis dose, 0.5 mg, report five units of J2778.

Don't forget to code the associated injection and medically indicated diagnosis.

You'll also report 67028 with modifier LT, RT, or 50 (Bilateral procedure). Link the codes to 362.52 (Exudative senile macular degeneration) (see "Look to 362.52 for Wet AMD Dx" on page 51).

CMS placed the average sale price (ASP) of a 0.1-mg dose of ranibizumab at $407.79. Medicare reimburses drugs at the ASP plus 6 percent, making the payment for five units of J2778 $2,161.29.

Code 67028 pays approximately $179.97 (4.99 transitioned total nonfacility relative value units [RVUs]), using the 2009 Medicare Physician Fee Schedule and a conversion factor of 36.0666 for services performed in the physician's office. Reimbursement for bilateral injections will be at 150 percent -- approximately $269.96.

Check Generic or Unclassified Rules for Avastin

Although the FDA has approved the drug to treat only colon or other cancers, many retina specialists are using Avastin off-label to treat wet AMD. One reason is price -- a 10-mg dose of Avastin has a Medicare ASP of $57.43, and ophthalmologists usually use an even smaller dose.

Which code? Unfortunately, Medicare carriers still  don't agree on how to code for Avastin to treat wet AMD, Zellmer notes. Some carriers (for example, Cahaba, the Part B carrier for Alabama, Georgia, and Mississippi) want the providers to use the HCPCS code for the generic version of Avastin, J9035 (Injection, bevacizumab, 10 mg). Others (such as National Government Services, carrier for Indiana, Illinois, Michigan, and Ohio) direct you to report J3490 (Unclassified drugs), and still others (such as Palmetto GBA in California) want providers to use J3590 (Unclassified biologics).

The size might be at the heart of the generic versus unclassified code debate. Because J9035 represents a 10- mg dose, and the typical dose for an intravitreal injection to treat wet AMD is 1.25 mg, J3590 is a more accurate choice, states Palmetto.

Good idea: Get your carrier's policy on reporting Avastin treatments in writing so you know which HCPCS code to report. Some carriers may require additional information on the claim. For instance, National  Government Services instructs providers to enter the phrase "Avastin for AMD" or "bevacizumab for AMD" into the claim's narrative field.

Most carriers agree that, on the same claim, you should also report 67028 for the drug's injection, as well as 362.52 to show medical necessity.

Be Prepared to Code Macugen ‘Unclassified'

Macugen, the first VEGF agent to become available, has its own HCPCS code: J2503 (Injection, pegaptanib  sodium, 0.3 mg). But in most areas, you'll need to use the unclassified drugs code J3490 instead, warns Zellmer.

Enter "Macugen" and the number of milligrams (for example, "0.3 mg") in box 19 of the CMS-1500 billing form or the electronic equivalent, she advises.

It's unclear why payers would prefer the unclassified code, notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "Per HIPAA guidelines, payers are required to accept the specific HCPCS code for the drug provided unless they have specified different instructions for coding the medication in the payerphysician contract or by referenced coding instructions, via Web site, bulletins, etc.," she says. Check with individual payers for Macugen billing preferences. For instance, in Florida, First Coast Service Options will look for J2503 on your Macugen claims, Zellmer says. The Medicare ASP for a 0.3 mg injection of Macugen is $1,036.38, bringing your practice $1,098.56 after adding 6 percent.

Include Components, Amounts in Claim

Following your electronic submission of the claims, your carrier may request additional information in the  form of an invoice showing the cost of the drug and require you to resubmit a manual claim for review with the invoice attached. When submitting the initial electronic claims, include in the narrative field the following:

• names of the components of these preparations

• amount of the drug

• invoice price for the preparation

• name of the pharmacy compounding the drug.

Keep a copy of the invoice in the beneficiary's medical record, available for review by the carrier, if requested. You may also need to submit information supporting a wet AMD diagnosis on appeal.

Records should include fluorescein angiography (92235, Fluorescein angiography [includes multiframe  imaging] with interpretation and report) or a comparable diagnostic test, such as optical coherence tomography (92135, Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser] with interpretation and report, unilateral).

If your carrier does not yet have a local coverage determination (LCD) for Lucentis, Avastin, or Macugen, you should have the patient sign an advance beneficiary notice (ABN). Be sure to append modifier GA (Waiver of liability statement on file) to 67028, as well as to the appropriate HCPCS supply code.