Ophthalmology and Optometry Coding Alert

Macular degeneration, thrust into the spotlight by recent advances in laser treatment, has a special set of coding challenges. First, coding fluorescein angiography (FA) is confusing because it may be done in one or both eyes sometimes the condition affects the eye with few symptoms. Second, the treatment for macular degeneration ocular photodynamic therapy (OPT) is new, costly and tricky to code.

The main diagnostic test to determine whether the macular degeneration is wet or dry is fluorescein angiography 92235 (fluorescein angiography [includes multiframe imaging] with interpretation and report). If there is some question about whether the condition is in the wet or dry form, the photos are usually done the same day as the dilated exam.

The distinction is important because OPT treats the classic form of wet macular degeneration only. When fluorescein angiography is performed, the ophthalmologist or technician usually takes photographs of the fellow eye as well, says Raequell Duran, president of Practice Solutions, a compliance, coding and reimbursement consultancy specializing in ophthalmology and based in Santa Barbara, Calif. The primary eye, designated as such by the physician, is photographed first after the dye is injected. Lates or late photos are taken on the fellow eye when the dye is already mostly through the vessels of the eye. If the FAs are done in both eyes, you should bill twice and be paid twice.

FA is unilateral for Medicare and most other payers. Medicares unilateral code policy for FAs stipulated the full fee schedule for each eye no 50 percent reduction for the second eye.

Coding the Treatment

Sometimes a patient with macular degeneration has a cystoid macular edema. In this case, the ophthalmologist uses a focal laser (67210) to treat the patient. But the main treatment is now photodynamic therapy new code 67221 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]). Bill for the drug Visudyne using HCPCS code J3490 (unclassified drugs).

Note: On the rare occasion when you perform the procedure in both eyes for a Medicare patient, bill G0184 for the procedure code.

Use modifier -57 (decision for surgery) when treating a patient with a laser on the same day that the patient is evaluated for the problem and the initial determination to do the laser is made, Duran says. Most ophthalmologists have lasers in their offices, including the new OPT laser. The -57 modifier is necessary in these cases because the visit would otherwise be denied as the preoperative workup considered included in the global surgery package.

Most Carriers Say OPT Has Zero-day Global

The focal laser, 67210, has a 90-day postoperative period, so any evaluation within that time would be covered by the global fee for the laser. OPT, however, has a zero-day global, according to many local payers. So you can bill for an evaluation if you need to see the patient at any time following the procedure.

Weve had some great improvements, like 20/200 vision after the OPT treatment, says John S. Bell, CEO of Maine Eye Associates, a five-ophthalmologist, four-optometrist practice based in Waterville, Maine. Old treatments for macular degeneration were intended to slow down the progression of the disease, Bell says. OPT can stop it.

Typically, ophthalmologists wait six weeks to bring the patient back for an evaluation. Most people need a repeat procedure, Bell says.

For treatment with OPT, when the physician evaluates the patient and also performs the FAs and OPT on the same day, the claim should appear as follows:

9921x-57 or 9201x-57 (depending on the documentation of the visit, examination performed, and LMRP for the eye codes)
67221-RT or -LT
92235-RT or -LT (or 92235-50 if both eyes done)
J3490 (until July 1, 2001 see Ophthalmologists Will Be Reimbursed by Visudyne)

There is no problem receiving payment, Bell says. But we still send the claims on paper, with supporting documentation. There is a letter of medical necessity, a diagnosis, a copy of the invoice for the Visudyne, and the size of the lesion. We continue to send it all, Bell says.

There is no official word yet on when coders can file electronically, cutting down on paperwork and time, for OPT. Unless you have instructions in a Medicare bulletin that tells you that you can, you are better off filing on paper.