Ophthalmology and Optometry Coding Alert

Code All Components of Ocular Photodynamic Therapy

Published on Sat Mar 01, 2003

Ocular photodynamic therapy (OPT), 67221, is used to treat the classic form of wet macular degeneration but if you don't know what components of OPT you can report, don't expect to be showered with reimbursements.

OPT is a noninvasive treatment for age-related macular degeneration that relies on the ability of a photoactive drug to destroy the degenerated cells targeted by the laser. But there are a number of components of OPT that are not included in 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]). Ask yourself the following three questions when coding OPT from start to finish to be sure your claims are appropriately reimbursed.

Code Bilateral 92235 Based on Documentation

The first question you should ask yourself when coding OPT is, Did the ophthalmologist order fluorescein angiography to be taken on one or both eyes?

Prior to determining whether a patient is a candidate for OPT, ophthalmologists have to confirm that the patient's macular degeneration is "wet," determined using fluorescein angiography (FA), 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report).

When fluorescein angiography is performed, it is not uncommon for the photographs of both the eye in question and the fellow eye to be taken regardless of whether macular degeneration is present in the fellow eye, says Ilan Hartstein, MD, a practicing ophthalmologist with La Palma Eye Care Center in California. This can sometimes be a tricky situation because coding FAbilaterally depends on what was ordered by the ophthalmologist and what the ophthalmologist has documented.

In the Medicare program, FA code 92235 is considered a unilateral code, Roxanne Oyler, CPC, business supervisor for Kentucky Eye Care in Louisville warns coders.
This means that if photographs are taken of both eyes, and there is evidence that both photographs were medically necessary, you will receive additional payment for a second FA. It also means that "you will need to use either modifier -50 (Bilateral procedure) or the alpha modifiers -RT and -LT if FAis taken for both eyes," she says.

For example, an ophthalmologist orders FA photos for a patient with edema in both eyes, 362.83 (Other retinal disorders; retinal edema). The bilateral edema constitutes medical necessity for billing bilateral FA: 92235-50, or 92235-RT and 92235-LT on separate lines. Carriers are very specific about how they want bilateral FA billed some may not recognize modifier -50, and others won't recognize the bilateral FA if it is billed on one line, Oyler says. "So be sure to check with your local carrier for their preferred method of billing bilateral FA."

If you do use the -50 modifier on one line, be sure to double your fee and check the Explanation of Medicare Benefits (EOMB), to make sure the carrier approved payment at 200 percent of the fee schedule, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif. "When the -50 modifier is used on surgical procedures, 150 percent of the fee schedule is approved for payment, but this is not true for a number of testing services, FA being one of them."

However, if an ophthalmologist orders FA for a patient with edema in his right eye but who is not symptomatic in his left eye, there is only medical necessity for the photos taken of the right eye: 92235-RT. Thus, you can only expect reimbursement for FA photos taken of the right eye. Medical necessity for the photographs is usually supported by extended ophthalmoscopy (92225, 92226), which includes a retinal drawing for the chart.

But don't assume it is always a good idea to bill for both FAs just because there is medical necessity for taking bilateral photos. There must be a documented request for the bilateral photos in the patient's chart. "It is very important to have documentation by the ophthalmologist of the ordering of FA photos, regardless of whether they are taken on one or both eyes," Oyler directs coders.

If the ophthalmologist orders FA photographs in the postoperative period of laser treatment, i.e., OPT, the second set of photos can be separately billable because OPT has a zero-day postoperative period and even if OPT had a 90-day global period, FAs are testing services and are not included in the global surgical package of procedures.

Apply 67221 and 67225 to Single and Multiple Eyes

When it comes down to coding OPT, you are going to be dealing with the following codes: 67221 and add-on code +67225 ( photodynamic therapy, second eye, at single session [list separately in addition to code for primary eye treatment]).

Lori H. Winnie, CPC, coding specialist with Southeastern Retina Associates in Chattanooga, Tenn., gives coders these guidelines for using the OPT codes:

Use 67221 for the first eye that undergoes OPT

Use +67225 for the second eye if it undergoes OPT in the same session as the first eye.

For example, suppose a patient presents for OPT in both eyes. The ophthalmologist performs OPT in the patient's right eye first, followed by the left eye. You would code this scenario 67221-RT, 67225-LT. Don't use modifier -50 (Bilateral procedure) or modifier -51 (Multiple procedures) to code OPT in both eyes at the same session, Winnie says.

Properly coding bilateral OPT using 67225 for the second eye indicates to the payer that the full allowable amount for 67225 should be paid without a multiple-surgery reduction. CPT guidelines also instruct coders never to append modifier -51 to an add-on code, a code preceded by a "+" sign.

However, if a patient presents for OPT in his left eye then four weeks later that patient returns for OPT in his right eye, you should bill 67221 for each procedure because they are not considered "at the same session," Winnie says; to meet this requirement, both eyes must be done at the same visit, and this is a rare occurrence.

So the second question you should ask yourself is, Which eye or eyes was the OPT performed in?

Sometimes a patient presents for an E/M service and the results of the evaluation prompt the ophthalmologist to perform OPT at that same patient encounter. Because the procedure itself has a zero-day global period, you need to use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or service) if an E/M service and 67221 are performed at the same patient encounter. Suppose a patient presents with severe senile macular degeneration in his left eye, which is confirmed by an FA. The ophthalmologist decides to perform OPT during the patient's same office visit. You would code this scenario 992xx-25 or 920xx-25, 92235-LT and 67221.

Don't forget that you can bill for any and all visits and services modifier-free when they are provided in the postoperative period of OPT because it has a zero-day global period.

Solidify Reimbursement with Safe ICD-9 Selection

Your third question should be, Does my ICD-9 code selection indicate medical necessity for OPT?

Determining covered diagnosis codes for Medicare patients is relatively easy, Winnie says, because CMS has a national coverage determination in place, which means all Medicare carriers are required to reimburse OPT if it meets the following requirements:

OPT must be performed in conjunction with verteporfin, otherwise known as Visudyne, Novartis and QLT

OPT is performed for a diagnosis of neovascular age-related macular degeneration and the patient presents with lesions where more than 50 percent of each lesion can be classified as "classic subfoveal choroidal neovascular," a diagnosis confirmed by FA photographs.

According to these guidelines, a diagnosis of 362.52, exudative senile macular degeneration, otherwise known as wet macular degeneration, is covered for OPT for all Medicare carriers and the vast majority of private and third-party payers. Some commercial carriers are not as consistent, Winnie warns, so to be sure you know what diagnosis codes are covered before performing the procedure, "Go ahead and call your carrier."

Don't expect reimbursement for OPT when the diagnosis is either pathologic myopia or presumed ocular histoplasmosis, both coded using 362.16 (Retinal neovas-cularization NOS). According CMS'NCD and Coverage Issues Manual, OPT is not covered for patients with:

a diagnosis of age-related macular degeneration with occult and no classic subfoveal choroidal neovascular lesions

diagnoses of other types of AMD, such as dry or atrophic AMD.

You are also entitled to reimbursement for the supply of the drug verteporfin, more commonly known as Visudyne, Winnie says. Physician groups should bill J3395.