Ophthalmology and Optometry Coding Alert

When the Food and Drug Administration (FDA) approved Visudyne last spring, ophthalmologists were able to use the drug to treat macular degeneration using ocular photodynamic therapy (OPT), but there was not a code for the service. Now, there is a new CPT code (67221) as well as new HCPCS codes for OPT. These codes will help ophthalmologists bill and be reimbursed for certain procedures that had no CPT codes before. The HCPCS codes will also enable Medicare to track the use and pricing of these services to aid in establishing relative value units (RVUs) for CPT codes that might follow later. These codes are effective for use for services performed on or after Jan. 1, 2001.

Eventually, there will be CPT codes for the services described by the new HCPCS codes. But while HCFA is waiting for CPT codes, HCPCS codes have been assigned temporarily. Historically when CPT publishes codes, the HCPCS codes are discontinued. (Occasionally, HCFA retains HCPCS codes even though there are new CPT codes to describe the services.)

More new relevant CPT codes, to replace or exist alongside the HCPCS codes, could be released as early as CPT 2002.

Ophthalmologists should use the new photodynamic therapy codes for Medicare patients getting one of these treatments. Medicare carriers will continue to recognize 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photocoagulation [e.g., laser], one or more sessions) for non-photodynamic laser treatment of localized lesions.

In addition, Medicare will recognize 67221 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) and has established a work RVU of 4.01 and a malpractice RVU of 0.52 for that service. Included in the global payment for 67221, according to the 2001 fee schedule as published in fall of 2000, are laser, infusion pump, slit lamp, opthaine, Mydriacyl, myolfrin, Goniosol, infusion kit (all infusion supplies), gloves, drape, gown and adhesive bandage.

It is significant that 67221 includes the infusion procedure but not the drug. The drug, Visudyne, is the most expensive part of the procedure, costing well above $1,000 for one dose. The drug is to be billed with the HCPCS code J3490 (unclassified drugs), notes Lise Roberts, vice president, Health Care Compliance Strategies, a Jericho, N.Y.-based compliance consulting company.

Code G0184 (destruction of localized lesion of choroid [e.g., choroidal neovascularization]; ocular photodynamic therapy [includes intravenous infusion], other eye) is for the OPT performed on the other eye. This add-on code has a work RVU of 0.47 and a malpractice RVU of 0.52; the supplies that are included are Opthaine, Mydriacyl, myolfrin and gonisol.

Other new G codes for new laser procedures that are still considered to be experimental are as follows:

G0185 destruction of localized lesion of choroid (e.g., choroidal neovascularization); transpupillary thermotherapy, one or more sessions

G0186 destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation, feeder vessel technique, one or more sessions

G0187 destruction of macular drusen, photocoagulation, one or more sessions.

Coverage and payment for the above G codes are at the discretion of local carriers, so watch your Medicare Bulletins for instructions. And remember to have the patient sign an advanced beneficiary notice (ABN) when performing the above services so you can bill the patient if the service is not covered.