Ophthalmology and Optometry Coding Alert

The FDA just approved the drug to treat AMD--read these tips to get ready to incorporate it into your coding

After the FDA’s recent approval, you might expect some ophthalmologists in your practice to start using ranibizumab injections (Lucentis) instead of pegaptanib sodium injections (Macugen) to treat macular degeneration. But if you think you can code the treatments the same way, you could earn a denial costing hundreds of dollars.
 
Read on for answers to your questions about coding for ranibizumab procedures.

Q: What kind of macular degeneration does ranibizumab treat?

A: The FDA approved ranibizumab on June 30, 2006, to treat neovascular (also known as “exudative” or “wet”) age-related macular degeneration (AMD), in which abnormal blood vessels grow behind the macula. ICD-9 code 362.52 (Exudative senile macular degeneration) describes this condition, says Vivian Passaro, CPC, compliance manager at the Bascom Palmer Eye Institute at the University of Miami School of Medicine. 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; however, you would use 362.52 to describe either form.

Q: Is there a specific HCPCS code for ranibizumab?

A: Not yet. Genentech, the manufacturer of the drug, recommends HCPCS code J3490 (Unclassified drugs) or J3590 (Unclassified biologics) for the supply of the drug. Although Medicare has not yet established a national policy for coding ranibizumab, at least two Part B carriers, Empire (New York and New Jersey) and Palmetto GBA (Ohio, South Carolina and West Virginia) have published articles specifying code J3590.

Both carriers direct you to enter the name “Lucentis” or “ranibizumab,” along with the dosage (e.g., 0.5 mg) in the narrative field of Item 19 of the CMS-1500 form or its electronic equivalent.

On the same claim, you will also need to report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug. Medicare’s 2006 Physician Fee Schedule values 67028 at a national average of $202.75 when performed in the office.

Bilateral procedures: Empire has spelled out special coding instructions for ranibizumab treatments in both eyes. “The drug must be reported on a separate claim line for each eye treated, using the appropriate site modifier, RT or LT,” the carrier says.

“Because J3590 is a miscellaneous code, the type of drug and amount have to be listed in the comment area, and you will have to attach an invoice for payment,” says Raequell Duran, CPC, president of Practice Solutions in Santa Barbara, Calif.

Watch out: Don’t use that strategy for coding bilateral injections, Empire says. If the ophthalmologist injects ranibizumab in both eyes, the carrier wants you to report 67028 on a single line and append modifier 50 (Bilateral procedure). The carrier should reimburse 67028-50 at 150 percent of the fee schedule amount for a single code--a national average of $304.13.

Example: An ophthalmologist injects both eyes of a wet-AMD patient with ranibizumab. According to Empire, proper coding for this scenario would be:

Line 1: 67028-50
Line 2: J3590-LT
Line 3: J3590-RT.

Q: What if the insurer denies the claim?

A: Even though FDA approval for a treatment usually means Medicare will reimburse for it, you may still run into problems with your local carrier, particularly if it doesn’t have a local coverage determination (LCD) for ranibizumab yet.

Be sure the patient’s documentation is comprehensive; you may need to submit information supporting a diagnosis of wet AMD on appeal. Records should include fluorescein angiography (92235, Fluorescein angiography [includes multiframe imaging] with interpretation and report) or comparable diagnostic test, such as optical coherence tomography (92135, Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral).

Smart idea: Genentech offers several resources for practices using ranibizumab, including a sample appeal letter, a sample letter of medical necessity, and the FDA’s letter approving the treatment. You can download them from www.spoconline.com/spoconline/lucentis/professional/forms/index.jsp.

If your carrier does not yet have an LCD for ranibizumab, it would be a good idea to have the patient sign an advance beneficiary notice (ABN), Duran says. “For the reason the service might not be covered, you can state that Medicare may consider it experimental and not medically necessary,” she says.

If the patient signs an ABN, be sure to append modifier GA (Waiver of liability statement on file) to codes 67028 and J3590.

Q: How much will Medicare reimburse for ranibizumab?

A: Although ranibizumab can cost up to $2,000 a dose, Medicare has yet to include the drug in its Drug Pricing Files. The agency reimburses Part B drugs at 106 percent of the average sales price.

“I don’t know if they will establish a payable amount until the drug has its own HCPCS code,” Duran says.