Ophthalmology and Optometry Coding Alert

Check CPT^® code descriptors and globals to keep your coding in compliance.

Age-related macular degeneration (AMD) is a leading cause of vision loss in adults over 60, so chances are your practice is seeing its share of patients with AMD. With so many macular degeneration cases, it’s crucial you periodically take stock of your coding practices to ensure you’re getting the best reimbursement for AMD-related services.

Ophthalmology coders must stay on top of the coding nuances for tests and treatments or risk letting AMD reimbursement fade away. Watch these three key areas to keep your AMD claims on track.

Know Which Tests Can Be Billed Separately

When your ophthalmologist suspects AMD, they’ll have the patient undergo several tests to confirm the diagnosis. Some are as simple as a dilated eye exam, visual acuity test, or fundoscopy. They may also perform fluorescein angiography if they think 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 fluorescein angiography takes to perform, experts note.

Performing all these 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 evaluation and management (E/M) service and are not separately billable, says Diane McVinney, CPC, billing manager at the Jones Eye Institute at the University of Arkansas for Medical Sciences in Little Rock. However, “fluorescein angiography is separately billable per eye when pathology is present,” she notes.

If your physician performs angiography, you have four coding options depending on the type of test and imaging:

• 92230 (Fluorescein angioscopy with interpretation and report)
• 92235 (Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral)
• 92240 (Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral)
• 92242 (Fluorescein angiography and Indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral)

Bilateral surgery indicators can be found in the Medicare Physician Fee Schedule (MPFS), says Sylvia Conrad, insurance coordinator with Your Eye Solution in Jacksonville, Florida. Medicare has assigned 92230 a bilateral indicator of “3” (payment based on 200 percent of the fee schedule when performed bilaterally) and 92235 and 92240 a bilateral indicator of “2” (payment based on 100 percent of the fee schedule when performed bilaterally as the procedures are defined as bilateral). The bilateral concept does not apply to 92242.

Keep an Eye on AMD Treatment Globals

Treatment plans for AMD run the gamut from “widely accepted” to “rarely considered reimbursable.” “Treatments are not normally combined, but some of the preventative measures can be done with procedures,” Zellmer says.

Injections are the treatment modality retina specialists typically turn to for their AMD patients. They’ll use one of the following injectable anti-vascular endothelial growth factor (VEGF) agents; report the supply with the appropriate HCPCS Level II code:

• Eylea^® – J0178 (Injection, aflibercept, 1 mg)
• Lucentis^® – J2778 (Injection, ranibizumab, 0.1 mg)
• Macugen – J2503 (Injection, pegaptanib sodium, 0.3 mg)
• Avastin^® – J9035 (Injection, bevacizumab, 10 mg)
• Byooviz™ – Q5124 (Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg)

You’ll also report 67028 (Intravitreal injection of a pharmacologic agent (separate procedure)) with modifiers LT (Left side), RT (Right side), or 50 (Bilateral procedure) for the injection.

The doctor may opt to treat AMD with photodynamic therapy using the drug Visudyne® (verteporfin). Instead of intravitreal injection, Visudyne is given via intravenous infusion and then activated by light in the eye. Report CPT^® code 67221 (Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes intravenous infusion)) for the procedure and HCPCS Level II code J3396 (Injection, verteporfin, 0.1 mg) for the drug.

For some patients, the physician may decide to treat AMD with laser photocoagulation, which you’ll report with 67210 (Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation).

Although historically more common, injectables are not the only option. A few ophthalmic practices are offering a tiny (pea-sized) telescope 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. The telescope insertion still only has a temporary CPT^® code: 0308T (Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis). Individual carriers price the code; there is no national reimbursement rate.

In an ambulatory surgery center (ASC) or hospital outpatient department, the ophthalmologist would report HCPCS Level II code C1840 (Lens, intraocular (telescopic)) for the supply of the device. While Medicare does not make separate payments for most devices described by C codes, the Centers for Medicare & Medicaid Services (CMS) expects hospitals to accurately code procedures and report C codes when applicable.

Watch your days: Many AMD treatments, such as 67210, carry a 90-day global period. Most descriptors also state that the code covers “one or more sessions,” so you can only report the initial treatment for the eye. When there are multiple sessions on the same eye during the global period, only the initial treatment is reimbursed — all the sessions are covered, just not separately billable. “If more treatments are needed within the 90-day global, you can only bill the medication — not the procedure,” Zellmer notes.

A few procedures don’t have a 90-day global period, so you should charge follow-up treatments when applicable. For example, injections of drugs such as Lucentis, Macugen, and Avastin (67028) and photodynamic therapy (67221) have a 0-day global.

Use These Modifiers for Accurate AMD Claims

As with other medical services, the wrong modifier can wreck an AMD claim. Finish your claim with modifiers 50, LT, or RT as appropriate. You might also need to append modifier 24 (Unrelated evaluation and management service by the same physician … during a postoperative period) or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service). “You can use modifier 24 if there is another problem that’s not related to the surgery,” Zellmer says.

Modifier 24 example: The patient sees your general ophthalmologist, has cataract surgery, and sees your retina specialist during the post-op period for follow-up of wet AMD. The wet AMD is unrelated to the cataract surgery, so you’ll append modifier 24 to the appropriate E/M code.

Modifier 25 example: A patient presents for evaluation of wet AMD right eye (OD), dry AMD left eye (OS), and worsening cataract bilaterally (OU). The ophthalmologist injects Anti-VEGF in the right eye and decides to proceed with cataract surgery in the left eye. The exam and encounter address more than the condition being treated by the injection and, thus, fits the description of “significant, separately identifiable E/M service.”