Ophthalmology and Optometry Coding Alert

Aflibercept generated last year’s highest allowed charges, CMS says.

Do you assume that your top-billed codes mainly involve cataract excisions and eye exams? Think again. When you go beyond CPT^® codes, you may realize that you’re frequently reporting HCPCS services.

That’s the word from CMS data, which indicates that J0178 (Injection, aflibercept, 1 mg) was the number one code in 2018 among all Part B physician/supplier data. It represented the most allowed charges last year at $2.4 billion. This drug, which is billed under the brand name Eylea, is used to treat macular degeneration.

On that same list, J2778 (Injection, ranibizumab, 0.1 mg) ranked third, with over $1.2 billion in allowed charges. This drug is billed when the physician administers Lucentis, which is used to treat a variety of eye-related conditions, including diabetic retinopathy, wet age-related macular degeneration, and macular edema.

If your eye care practice ranked among the offices submitting these codes last year, read on to find out some best practices on how to appropriately report these services.

You’ll Almost Never Report These Drugs Alone

The codes above represent injectable anti-vascular endothelial growth factor (VEGF) agents, and your practice will almost always report them with CPT^® codes that represent the actual injection procedures.

To reflect the drug administration itself, you’ll typically report 67028 (Intravitreal injection of a pharmacologic agent (separate procedure)) with modifier LT (Left side), RT (Right side), or 50 (Bilateral procedure) for the injection. Although many practices are aware of reporting the combination of the HCPCS code with the CPT^® code, not all coders bill both — and they are losing reimbursement due to the oversight. In the office setting 67028 brings in about $104, so failing to report that code can cause big issues with your reimbursement if you repeatedly forget to bill it.

Calculate the Units

To determine how many units of J0178 or J2778 to report, always check the documentation and determine how many milligrams the physician injected. Then calculate how many units of the drug that represents. For example, if you administer the standard Lucentis dose, 0.5 mg, report five units of J2778.

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).

Resource: To read the most-billed Medicare services, visit  https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/Downloads/Level2Charg18.pdf.