Ophthalmology and Optometry Coding Alert

On March 28, 2002, CMS announced that ophthalmologists cannot use 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]), also known as ocular photodynamic therapy (OPT), for occult lesions of age-related macular degeneration (AMD). CMS will cover OPT for classic lesions only.

Instead of using 67221 for occult lesions, you should advise the patient that he or she will be responsible for payment and ask the patient to sign an advance beneficiary notice, advises Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding and compliance consultancy. The ABN should tell the patient that "Medicare considers this procedure to be experimental and does not offer coverage for such procedures," Duran says.

CMS, which has covered OPT for classic lesions since July 2001, announced last fall that it planned to cover OPT for occult lesions. After experts raised questions, CMS decided to re-review the clinical trial data. Despite the American Academy of Ophthalmology and the Vitreous Society's recommendation that 67221 should be considered for some patients with occult and no classic lesions, CMS reversed its decision, citing that OPT's benefit for occult lesions isn't great enough to warrant coverage. OPT "is not a cure," CMS states: AMD patients have already lost vision, and will continue to lose vision even after treatment. "Any days of preserved vision that may result from treatment are not days of normal vision, but are days of moderately to severely limited visual function," CMS reasons.

Occult denotes a wet form of lesion that is not visible to the eye even with extended ophthalmoscopy (92225, Ophthalmoscopy, extended, with retinal drawing [e.g., for retinal detachment, melanoma], with interpretation and report; initial; and 92226, subsequent), Duran explains. To detect and evaluate the lesions, the ophthalmologist then uses other techniques 92235 (Fluorescein angiography [includes multiframe imaging] with interpretation and report) and, if that doesn't work, 92240 (Indocyanine-green angiography [includes multiframe imaging] with interpretation and report). Because no specific diagnosis code exists for occult lesions of AMD, you should link any covered procedures to 362.52 (Degeneration of macula and posterior pole; exudative senile macular degeneration).

Note: CMS coverage policy on OPT for classic lesions remains unchanged, so you can continue to use 67221 with 362.52.