Ophthalmology and Optometry Coding Alert

Medicare may allow the treatment for AMD, even without FDA approval

You may be able to start coding for bevacizumab (Avastin) injections to treat AMD--but selecting the right HCPCS code for the supply is still tricky.

Until recently, the chances of getting reimbursed by Medicare for off-label use of bevacizumab to treat macular degeneration were very slim. The FDA had approved the drug, but only to treat colon and rectal cancer.

However, recent journal articles have begun to convince Medicare carriers of the scientific evidence that bevacizumab injections are effective in treating wet age-related macular degeneration (AMD), after other treatment options have failed.

Several carriers have published articles stating that they will reimburse bevacizumab claims for dates of service starting June 1, 2006.

Snag: They don't all agree on what HCPCS code to report for the supply of the drug.

Smaller Dosage May Determine Coding

Bevacizumab does have its own HCPCS code: J9035 (Injection, bevacizumab, 10 mg), says Karen Bartrom, CPC, coder for Vitreo-Retinal Consultants in Indianapolis. But many carriers have only approved intraocular injections of the drug in 1.25-mg doses, so a pharmacy must compound the drug into smaller doses. Because J9035 specifies a 10-mg dose, the code may not be appropriate for a smaller dose, some carriers reason.

Some carriers (such as GHI and Empire in New York and New Jersey) direct you to report J3490 (Unclassified drugs), while others (such as Cahaba, Part B carrier for Alabama, Georgia and Mississippi; and Palmetto, carrier for Ohio, South Carolina and West Virginia) expect J3590 (Unclassified biologics).

Noridian, the Part B carrier for 12 western states, expects J9035 for bevacizumab to treat wet AMD. Addressing the dosage discrepancy, Noridian directs coders to "[p]lace the number of mg used in Item 24G on the CMS-1500 claim form or the electronic equivalent. When billing for dosages of less than one mg, round up to the next whole mg. The individual patient record should clearly document the amount of drug used for each patient. Also, the amount wasted should be clearly indicated in the medical record."

Arkansas BlueCross BlueShield (which also administers the Part B program in Rhode Island) and CIGNA (Idaho, North Carolina and Tennessee) list both J3590 and J9035 as acceptable codes.

All the carriers agree that 362.52 (Exudative senile macular degeneration) is the only acceptable ICD-9 code.

Don't miss: Report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug.
 
Enter "Avastin (or bevacizumab) and the dosage for macular degeneration" in Item 19 or the comments area of the CMS-1500 claim form, says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.

Prove Patient Consent With Documentation

Your carrier may require proof that other wet-AMD treatments have failed and that the patient understands the risk involved in accepting bevacizumab injections. Make sure your records show the following:

• documentation that the patient has failed to improve or stabilize using other currently accepted therapies, such as Visudyne (verteporfin) and Macugen (pegaptanib sodium)

• results of at least two fluorescein angiograms (92235) and optical coherence tomography (92135)

• screening for medical conditions that would contraindicate the use of bevacizumab, including gastrointestinal hemorrhage or perforations, wound healing complications, other hemorrhage, arterial thromboembolic events, hypertension, proteinuria and heart failure

The records should also include a statement that the patient is aware of potential complications and that the ophthalmic use of bevacizumab is off-label.

The medical record must contain the actual dosage, site, the lot number of the vial, date and time of administration, and any unusual reactions.