Ophthalmology and Optometry Coding Alert

Hint: Check bilateral status before coding.

Nearly 2 million Americans have age-related macular degeneration (AMD), and more than 7 million are at risk, so chances are your ophthalmology practice is seeing more AMD patients. Are you getting the best reimbursement for all AMD’s related services? Watch these areas to ensure you file correctly for this growing area of ophthalmology care.

1. Combine Services for Diagnosis

When your ophthalmologist suspects AMD, he’ll complete several tests to confirm the diagnosis. Some are as simple as a dilated eye exam, visual acuity test, or fundoscopy. He might also complete a fluorescein angiography if he suspects a patient might have wet AMD. These can all be done on the same day, but it would be unlikely due to the amount of time that a fluorescein angiography takes to perform, experts note.

Performing all the diagnostic tests on the same day, however, doesn’t mean they’re separately billable. Visual acuity and fundoscopy are part of the eye exam or E/M, and are not separately billable. Fluorescein angiography is separately billable per eye when pathology is present.

If your ophthalmologist completes fluorescein angiography, you have three coding options depending on the type of test and imaging:

• 92230 — Fluorescein angioscopy with interpretation and report
• 92235 — Fluorescein angiography (includes multiframe imaging) with interpretation and report
• 92240 — Indocyanine-green angiography (includes multiframe imaging) with interpretation and report.

You can find the bilateral surgery indicators in the Medicare fee schedule. Medicare assigns codes 92230-92240 a bilateral surgery modifier indicator of “3.” This means that if you report a fluorescein angiography procedure with modifier 50 (Bilateral procedure), or if you report it for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), Medicare will base reimbursement on 100 percent of the allowed amount for each side, without applying a bilateral fee adjustment.

You’ll submit a diagnosis based on whether your physician confirms dry or wet AMD. Report 362.51 (Nonexudative senile macular degeneration) for dry AMD or 362.52 (Exudative senile macular degeneration) for wet AMD.

Other possibilities: ICD-9 includes two more diagnostic choices for AMD, though you won’t rely on them as often. Code 362.50 (Macular degeneration [senile], unspecified) isn’t normally used because the physician can tell what type it is by the examination performed. Alternatively, you’ll use 362.53 (Cystoid macular degeneration) if there is swelling and a cyst is located in the macula.

2. Know Globals for Your Treatments

Some of the more common treatment plans for AMD include:

• Lucentis injections — J2778 (Injection, ranibizumab, 0.1 mg) for the drug; 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection. The procedure is relatively painless, but there is a risk of eye infection or detached retina.
• Macugen injections — J2503 (Injection, pegaptanib sodium, 0.3 mg) for the drug; 67028 for the injection. Macugen can cause many more non-ocular side effects, including chest pain, arthritis, CVA, diabetes, urinary retention, vertigo, and vomiting. Macugen can lead to increased intraocular pressures and injections must be performed once every six weeks.
• Laser photocoagulation — 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation). The laser destroys the fragile, leaky blood vessels. However, treatment may also destroy some surrounding healthy tissue and some vision. Only a small percentage of patients with wet AMD can be treated with laser surgery. The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. Sometimes vision loss may progress despite these repeated treatments.
• Photodynamic therapy — 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) for the procedure; J3396 (Injection, verteporfin, 0.1 mg) for the drug. The ophthalmologist injects verteporfin (brand name Visudyne) into the patient’s arm and activates it by light. The activated drug destroys the new blood vessels (without destroying surrounding healthy tissue) and leads to a slower rate of vision decline. However, the patient must avoid exposing his skin or eyes to direct sunlight or bright indoor light for five days after treatment. This therapy does not stop vision loss or restore vision in eyes already damaged by advanced AMD. 

Watch your days: Many AMD treatments carry a 90-day global period (such as 67210, Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation). Most also state that the code covers “one or more sessions,” so you can only report the initial treatment for the eye.

When there are multiple sessions on the same eye during the global period, only the initial treatment is covered. If more treatments are needed within the 90-day global, you can only bill the medication — not the procedure, experts advise.

A few procedures don’t have a 90-day global period, however, so remember to charge follow-up treatments when applicable. For example, injections of drugs such as Lucentis, Macugen, and Avastin (67028) and photodynamic therapy (67221) have a 0-day global.

3. Choose Your Visit Code Carefully

Ophthalmologists have the choice of using either eye codes (92002-92014) or outpatient E/M codes (99201-99215) for their examinations.

Some Medicare payers have local coverage determination policies on the eye codes, with specific guidelines as to what needs to take place to use the eye codes. Some states also have policies on the specific elements that must be performed for the comprehensive eye exams. Other Medicare payers do not have such policies. When that is the case, physicians should use the descriptor in CPT^® as a guideline for what needs to take place to qualify for an intermediate or comprehensive eye exam.