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 [...]