Ophthalmology and Optometry Coding Alert

Know which type of AMD the patient has for complete coding success.

Age-related macular degeneration (AMD) is one of the leading causes of blindness in the U.S., and it’s showing no signs of going away any time soon. According to the National Eye Institute, by 2050, the estimated number of people with AMD is expected to more than double from 2.07 million to 5.44 million. Which means your practice will continue to see plenty of AMD cases for the foreseeable future.

With so many AMD patients, the condition has its share of misconceptions for coders and billers in ophthalmology practices. Is one of these AMD myths putting a wet blanket on your coding success? 

Don’t Bill All Tests Separately

Myth: When several tests are necessary to diagnose wet AMD, you can bill for them separately.

Reality: 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 (CPT® code 92235) is separately billable per eye when pathology is present. 

Bilateral billing is allowed with 92235, with full payment for each eye, either on one line with modifier 50 (Bilateral procedure) or on two lines with modifiers LT (Left side) and RT (Right side) appended, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

Wet or Dry Determines Dx

Myth: A single diagnosis code describes age-related macular degeneration.

Reality:The diagnosis code you report depends on the type of AMD present in the patient.

Background: Macular degeneration occurs when the small central portion of the retina, known as the macula, deteriorates. It can be diagnosed as either dry or wet AMD.

Dry: If the patient suffers from nonexudative – otherwise known as dry or atrophic – senile (age-related) macular degeneration, report ICD-9 code 362.51 (Nonexudative senile macular degeneration) before Oct. 1, 2015. After that date, the ICD-10 codes take effect, and you would report H35.31 (Nonexudative senile macular degeneration). In dry AMD, yellowish cellular debris called drusen accumulates, which can cause atrophy and scarring to the retina. Dry AMD is more common and less severe, but can lead to the more severe wet AMD.

Wet: If the patient suffers from exudative – also known as disciform or wet – senile macular degeneration (sometimes called Kuhnt-Junius degeneration), report ICD-9 code 362.52 (Exudative senile macular degeneration). After Oct. 1, 2015, report ICD-10 code H35.32 (Exudative age-related macular degeneration). In wet AMD, which is more severe than the dry form, blood vessels grow behind the retina, leaking blood and fluid.

Wet AMD falls into two categories: occult and classic. Whichever the category of wet AMD, however, the diagnosis code would still be 362.52 or H35.32. 

Myth: Injectable drugs are the only treatment for AMD.

Reality: Although certainly historically more common, injectables are not the only option. Some ophthalmic practices are offering a tiny (pea-sized) telescope manufactured by CentraSight, implanted behind the iris to project images onto the non-degenerated portions of the patient’s macula. The telescope enlarges the image, reducing the patient’s blind spot.

Approved in 2010, the telescope insertion still only has a temporary CPT® code: 0308T (Insertion of ocular telescope prosthesis including removal of crystalline lens). Individual carriers price the code; there is no national reimbursement rate.

In an ASC or hospital outpatient department, you would report HCPCS code C1840 (Lens, intraocular [telescopic]) for the supply of the device. While Medicare does not make separate payment for most devices described by C codes, CMS expects hospitals to accurately report and code procedures and report C codes when applicable.

More commonly, your ophthalmologist will turn to one of the following injectable anti-vascular endothelial growth factor (VEGF) agents for their AMD patients, reported with these HCPCS codes for the supply:

• Lucentis: J2778 (Injection, ranibizumab, 0.1 mg)

• Eylea: J0178 (Injection, aflibercept, 1 mg)

• Macugen: J2503 (Injection, pagaptanib sodium, 0.3 mg)

You’ll also report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) with modifier LT, RT, or 50 (Bilateral procedure) for the injection. 

The ophthalmologist may also opt to treat AMD with photodynamic therapy, using the drug Visudyne. Instead of an ocular injection, Visudyne is given through an intravenous injection in the arm, then activated by light in the eye. 

Report CPT® code 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) for the procedure; HCPCS code J3396 (Injection, verteporfin, 0.1 mg) for the drug.

For a small percentage of patients, the ophthalmologist may choose laser photocoagulation – CPT® code 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation).