Ophthalmology and Optometry Coding Alert

Remember: Single-use vials are meant to be billed only for one patient.

Billing payers for multiple doses of single-use medications may seem like a simple mistake, but for one ophthalmology practice, doing those things will cost nearly $5 million.

A Florida eye care practice has agreed to pay $4.8 million to resolve allegations of healthcare fraud for its part in what was said to be a repeated pattern of billing Medicare, Tricare, and the Federal Employees Health Benefits Program for multiple doses of Lucentis and Eylea when they simply took more than one dose from single-use vials.

“Anyone who seeks to exploit our healthcare system by submitting false claims to our federal health care programs will be held accountable for their actions,” said U.S. Attorney Maria Chapa Lopez in a recent statement about the case. “Today’s settlement makes clear that the protection of our nation’s health programs is a priority for our Office and the Department of Justice.”

Background: When treating patients with wet age-related macular generation or other eye diseases, eye care physicians sometimes administer Lucentis or Eylea injections. However, each of these drugs is packaged in a single-dose vial, which is billed for one patient at a time. It’s inappropriate to take multiple doses of that medication and administer it to a variety of patients while still billing insurers as if multiple vials were used.

Stay on the Straight and Narrow With These Tips

You can avoid this practice’s fate by ensuring that you’re coding these services properly. When you report Lucentis injections using the indicated single dose, 0.5 mg, you should report five units of J2778 (Injection, ranibizumab, 0.1 mg). On the same claim, report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug. Most insurers will accept a code from the H35.32xx (Exudative age-related macular degeneration) series to prove medical necessity for an intravitreal Lucentis injection.

If your provider injects both eyes, report 67028 with modifier 50 (Bilateral procedure) or with modifiers LT (Left side) and RT (Right side). In addition, don’t forget to calculate how many units of the drug you should bill, since it may be higher than the standard 0.5 mg dose.

Therefore, if you inject 0.5 mg of Lucentis into the patient’s left eye to treat exudative age-related macular degeneration, you’d report 67028-LT, J2778 x 5, and H35.3220 (Exudative age-related macular degeneration, left eye, stage unspecified).

Unilateral services: In the past, physicians have been known to bill bilateral Lucentis injections even when patients only had one eye, which is another fraudulent practice. To avoid operating this way, you must get to know which codes are inherently bilateral. For example, Medicare considers 92250 (Fundus photography with interpretation and report) to be inherently bilateral. In other words, the payer bases its reimbursement on the procedure being performed on both eyes.

Don’t miss: If the ophthalmologist only photographs one eye, modifier 52 (Reduced services) may be your best bet, say experts. You can then append modifier LT (Left eye) or RT (Right eye) to specify which eye was photographed, although those modifiers are informational and do not affect reimbursement.

Resource: To read the government release about the case, visit www.justice.gov/usao-mdfl/pr/sarasota-based-ophthalmic-consultants-agrees-pay-48-million-resolve-claims-multi-dosing.