Ophthalmology and Optometry Coding Alert

Also: Follow carrier rules for Avastin treatments -- or risk losing $57 a dose

Good news for ophthalmology coders: Two popular drugs to treat wet AMD finally have their own HCPCS codes. The bad news: In some cases, you may still have to report them with "unclassified" codes -- or face denials.

Since the FDA approved ranibizumab injections (Lucentis) to treat wet age-related macular degeneration (AMD) in 2006, ophthalmologists have been increasingly using the drug. Previously, coders had to resort to an "unclassified" code to report Lucentis -- but that all changed in 2008.

However: If your practice uses bevacizumab to treat wet AMD, you may still have to use that "unclassified" code -- even though the drug (trade name Avastin) has had its own HCPCS code for years.

Start Using New J Code for Lucentis

The FDA approved Lucentis on June 30, 2006, to treat neovascular (also known as "exudative" or "wet") AMD, in which abnormal blood vessels grow behind the macula. Code 362.52 (Exudative senile macular degeneration) describes this condition, says Diane McVinney, CPC, billing manager at the Jones Eye Institute at the University of Arkansas for Medical Sciences in Little Rock. Wet AMD usually progresses from non-neovascular, or "dry" AMD (362.51, Nonexudative senile macular degeneration), which is the more common condition.

Depending on the nature of the neovascularization, an ophthalmologist may further classify wet AMD as either classic or occult. Nonetheless, you would use 362.52 to describe either form.

New code: Effective Jan. 1, 2008, you can report Lucentis treatments with a new permanent HCPCS code, J2778 (Injection, ranibizumab, 0.1 mg), McVinney says. Previously, carriers directed coders to report J3490 (Unclassified drugs) or J3590 (Unclassified biologics) for the drug supply, she says.

For the indicated single Lucentis dose, 0.5 mg, report five units of J2778. On the same claim, report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug. Most insurers will only accept 362.52 to prove medical necessity for an intravitreal Lucentis injection.

If your provider injects both eyes, report 67028 with modifier 50 (Bilateral procedure), says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "Alternatively, you may report 67028 with modifiers LT and RT on two lines," she says.

CMS placed the average sale price (ASP) of a 0.1-mg dose of ranibizumab at $408.887. Medicare reimburses drugs at the ASP plus 6 percent, making the payment for five units of J2778 $2,167.10.

Code 67028 pays approximately $193.10 (5.07 transitional total nonfacility relative value units [RVUs]), using the 2008 Medicare Physician Fee Schedule and a conversion factor of 38.0870 for services performed in the physician's office. Reimbursement for bilateral injections will be at 150 percent, Mac says -- approximately $289.65.

Be Prepared to Code Avastin 'Unclassified'

Alternate: Although the U.S. Food and Drug Administration has only approved the drug to treat cancer, 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 $57.46, and ophthalmologists usually use a smaller dose.

Controversy: Ophthalmologists feared that they would lose this option after Genentech, which manufactures Avastin and Lucentis, announced that it would no longer distribute Avastin to compounding pharmacies.

Ophthalmologists need compounding pharmacies to divide Avastin into the smaller vials necessary for wet AMD treatment. Genentech intended to steer ophthalmologists toward Lucentis, which it developed specifically to treat wet AMD.

But the manufacturer, in collaboration with the American Society of Retinal Specialists (ASRS) and the American Academy of Ophthalmology (AAO), has announced that it will provide the drug to wholesalers, who can then reship it to compounding pharmacies. Now that Avastin is again becoming a viable treatment option, be prepared for the coding challenge.

Which code? Unfortunately, Medicare carriers still don't all agree on how to code for Avastin to treat wet AMD. Some carriers (for example, Cahaba, the Part B carrier for Alabama, Georgia and Mississippi) want the HCPCS code for Avastin, J9035 (Injection, bevacizumab, 10 mg). Others (such as National Government Services) direct you to report J3490, and still others (such as Palmetto GBA) want providers to use J3590.

Rationale: 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, Palmetto says.

Get It in Writing

Good idea: Get your carrier's policy on reporting Avastin treatments in writing so you know which HCPCS code to report. Enter the phrase "Avastin for AMD" or "bevacizumab for AMD" into the claim's narrative field, National Government Services says.

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.

When in Doubt, Consider an ABN

Documentation: You may also need to attach an invoice to the claim. If you don't, you may need to include the following in the narrative field:

• the names of the components of these preparations

• the amount of the drug

• the invoice price for the preparation

• the 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 or Avastin, 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.