Ophthalmology and Optometry Coding Alert

With only three months to go until 2001, its time to be sure youre ready for the two main proposed revisions to payment policies under the Medicare Physician fee schedule for the new year. One is a decrease in relative value units (RVUs), and the other is a new code for photodynamic therapy (PDT).

New Codes and Values

There are now codes and RVUs proposed for PDT, as well as codes for tracking purposes for experimental procedures, including transpupillary thermal therapy (TTT), destruction of macular drusen by photocoagulation and feeder-vessel technique photocoagulation. The Health Care Financing Administration (HCFA) assigns tracking codes to follow the extent to which ophthalmologists are providing these experimental services.

Tracking codes are important because without them physicians must use the unlisted code, which does not describe the services.

The proposed rule also includes a crosswalk from 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization], one or more session, photocoagulation [e.g., laser, ocular photodynamic therapy]) to 67208 (destruction of localized lesion of retina [e.g., macular edema, tumors], one or more sessions; cryotherapy, diathermy). This corrects an anomaly left over from last Novembers Medicare fee schedule, in which 67220 did not have a cost assigned to it.

The calculation of practice expense RVUs as proposed by HCFA would, if adopted, decrease total allowed charges for ophthalmologists by one percent, according to the American Society of Cataract and Refractive Surgery. This is due to a correction in the supply lists for some in-office codes, as well as a recalculation of the practice expense per hour.

PDT Changes

For CPT 2000, PDT was added to the descriptor of 67220. PDT, however, is significantly different from photocoagulation, according to the Medicare fee schedule released in July. Therefore, HCFA is proposing to establish two new HCPCS codes: one for photocoagulation, and one for PDT. The new codes and descriptors would be as follows.

Gxxx5: (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photocoagulation [e.g. by laster], one or more sessions)

The above code would be used in place of 67220 for Medicare patients.

Gxxx6: (destruction of localized lesion of choroid [e.g., choroidal neovascularization: ocular photodynamic therapy [includes intravenous infusion])

The above code would be used for PDT for Medicare patients. As indicated, it will include the cost of administering the Visudyne, but not the cost of the drug itself.

Note: For more on PDT and Visudyne see preceding article HCFA Wants 67299 for PDT.

Although there are no CPT codes currently for the above services, there will be. When HCFA is waiting for a code to be approved for CPT, the agency commonly assigns the service a HCPCS code as a temporary measure. HCPCS codes are those codes with one alphabet character (A, B, C, etc.) and four numerals. HCFA also assigns HCPCS modifiers that eventually turn into numbers. When the codes appear in CPT, HCFA will discontinue use of the HCPCS version.

The proposed work value for Gxxx6 (PDT) is 0.55 RVUs. This RVU was arrived at by halving the work value for 96570 (photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]), and it is the same as the work value for 96571 (photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; each additional 15 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]). The total time of laser light application for ocular photodynamic therapy is 83 seconds, which is considerably shorter than the time of laser light application for CPT codes 96570 and 96571.

How did HCFA come to compare aiming light at a retina to an endoscopic procedure? The answer lies in the drug manufacturer publishing the information that PDT is a simple procedure that takes 83 seconds. Because of this, HCFA didnt want to reimburse for the service at any level close to 67220. Also, keep in mind that this is just a proposed rule and that the work value could be raised.

Finally, HCFA is proposing that there be no global period for PDT. This means that you can bill other services on the same day, including fluorescein angiography (92235) and an evaluation and management (E/M) service (if separately identifiable and with the modifier -25 appended). It also means that any E/M services performed after the treatment may be billed separately.

If both eyes are treated the same day, HCFA is also proposing an add-on code, which would be Gxxx7 (destruction of localized lesion of choroid [for example, choroidal neovascularization]; ocular photodynamic therapy [includes intravenous infusion] other eye [list separately in addition to Gxxx6]). The add-on code will have no global period and an RVU of .l28.

Experimental Procedures: Tracked, Not Paid

In addition, there are three other HCPCS codes which are being proposed for similar treatments. These are experimental procedures and will not have any RVUS, but are being established for tracking purposes only. This means that carriers are being instructed not to pay.

The codes are as follows:

Gxxx8 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; transpupillary or thermal therapy, one or more sessions)

Gxxx9 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photocoagulation, feeder vessel technique, one or more sessions)

Gxxx10 (destruction of macular drusen, photocoagulation, one or more sessions)

The reason that HCFA wants to set national HCPCS codes and payment amounts for PDT is simply to have control over pricing. If we did not establish national codes and pricing for this procedure, carriers that determined that this procedure is covered would use unlisted codes and determine pricing locally, the Federal Register announcement states.

RVUs of Commonly Used Codes

Here is how the proposed changes would affect some commonly used codes:

66821 (discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; laser surgery [e.g., YAG laser] [one or more stages]): 4.321 percent increase

66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]): no change

92004 (ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits): .42 percent decrease

92012 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient): 1 percent decrease

92014 (ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits): .621 percent decrease.