Ophthalmology and Optometry Coding Alert

Is the patient's CNV classic or occult?  The answer could be worth $323

Ophthalmologists frequently use lasers combined with photoactive drugs to treat "wet" AMD. And if you ignore the rules for OPT documentation and bilateral coding, you are sure to dampen your chances for receiving the full pay for these treatments.

The CPT code for ocular photodynamic therapy is 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]), says Denise Voyles, CPC, coding specialist with the Vitreoretinal Foundation Eye Specialty Group in Memphis. OPT is a noninvasive treatment for age-related macular degeneration (AMD) that relies on the ability of a photoactive drug to destroy the degenerated cells targeted by the laser. Medicare approved the procedure in 2001--but they've since changed the conditions for which they find it "reasonable and necessary." Follow these steps to make sure you're on top of the latest CMS requirements for coding OPT.

Step 1: Determine the Extent of CNV

Thorough documentation is the key to satisfying Medicare that an OPT treatment is medically necessary. According to CMS' national coverage determination (NCD), found in section 80.2.1 of the Medicare National Coverage Determinations Manual, it is only covered when used in conjunction with verteporfin, an intravenous photosensitive drug that can destroy neovascularizations in the eye when exposed to light.

Until April 2004, Medicare only approved OPT with verteporfin to treat neovascular AMD--362.52 (Exudative senile macular degeneration)--with predominantly classic subfoveal choroidal neovascularization (CNV) lesions.

Now: Medicare revised its policy in 2004 to allow for OPT with verteporfin to treat subfoveal occult (hidden) CNV and subfoveal minimally classic CNV associated with AMD, in which the area of classic CNV covers less than 50 percent of the lesion. However, CMS only considers treatments for those two conditions reasonable and necessary when:

• The lesions are small (four disk areas or less in size) at the time of initial treatment or within the three months prior to initial treatment; and

• The lesions have shown evidence of progression within the three months prior to initial treatment.

To provide "evidence of progression," your documentation must include one of the following:

• Deterioration of visual acuity (at least five letters on a standard eye examination chart)

• Lesion growth (an increase in at least one disk area)

• Appearance of blood associated with the lesion.

Note: To see Medicare's NCD for OPT, visit http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp.

Carriers may differ on how they want you to report occult or minimally classic CNV. Although 362.52 describes all kinds of "wet" AMD--with classic, minimally classic, or occult CNV--some carriers ask you to report 362.50 (Macular degeneration [senile], unspecified) as a diagnosis code for non-classic AMD.

Other causes: If AMD isn't the cause of the CNV at all, Medicare leaves it up to the local carriers whether they'll cover OPT for neovascularization caused by other diseases. If the patient's CNV is caused by ocular histoplasmosis (115.02, Infection by Histoplasma capsulatum; retinitis) or pathologic myopia (360.21, Degenerative disorders of globe; progressive high [degenerative] myopia), report 362.16 (Retinal neovascularization NOS). Depending on your local carrier's preferences, you may also need to report 115.02 or 360.21 in addition to 362.16.

Step 2: Report Both Sides of FA

A crucial part of your documentation is the fluorescein angiogram (92235, Fluorescein angiography [includes multiframe imaging] with interpretation and report), which determines what kind of AMD is present. Often, the ophthalmologist will perform 92235 on both eyes, regardless of whether macular degeneration is present in the fellow eye.

In the Medicare program, FA code 92235 is considered a unilateral code, says Rebecca Taylor, CPC, OCS, coder and accounts receivable supervisor at the Tri-State Center for Sight in the Cincinnati area. This means that if photographs are taken of both eyes, and there is evidence that both photographs were medically necessary (and there is a documented request for bilateral photos in the patient's chart), you will receive additional payment for a second FA.
 
It also means that you will need to use either modifier 50 (Bilateral procedure) or the alpha modifiers RT and LT if FA is taken for both eyes, Taylor says.

Example: An ophthalmologist orders FA photos for a patient with neovascularization in both eyes. The bilateral neovascularization constitutes medical necessity for billing bilateral FA: 92235-50, or 92235-RT and 92235-LT on separate lines.

However, if an ophthalmologist orders FA for a patient with neovascularization in his right eye but who is not symptomatic in his left eye, there is only medical necessity for the photos taken of the right eye: 92235-RT. Thus, you can only expect reimbursement for FA photos taken of the right eye.

Step 3: Code 67221 and 67225 for Both Eyes

Report the OPT procedure itself with 67221 and add-on code +67225 (... photodynamic therapy, second eye, at single session [list separately in addition to code for primary eye treatment]).

Report 67221 for the first eye that undergoes OPT. Report +67225 for the second eye if it undergoes OPT in the same session as the first eye.
 
However, if a patient presents for OPT in his left eye then returns four weeks later for OPT in his right eye, you should bill 67221 for each procedure, Voyles says. Code 67225 is not appropriate for the procedure done on the right eye, because it did not occur at the same session as the first eye.

If the OPT is taking place in the office, you can also code for the supply of the drug verteporfin (also known as Visudyne) with J3396 (Injection, verteporfin, 0.1 mg). But note that the definition of 67221 specifies that it "includes intravenous infusion." Therefore, do not separately report an injection code, Taylor says.
 
Most important: When J3396 replaced J3395 this year for verteporfin injections, HCPCS changed the units from 15 mg to 0.1 mg. Therefore, for services in 2005 and later, if the ophthalmologist injects a full 15-mg vial of the drug, you should report 150 units.