Ophthalmology and Optometry Coding Alert

The Health Care Financing Administration (HCFA) is cracking down on photodynamic therapy (PDT) even before the treatment becomes widely used. HCFAs problem with PDT has nothing to do with the fact that its new (it is no longer experimental). Rather, HCFA is concerned about the high expense of the drug used for PDT, Visudyne (verterporfin), which the FDA approved in April.

Although many ophthalmologists were using code 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization], one or more session, photocoagulation [e.g., laser, ocular photodynamic therapy]) for photodynamic therapy because it includes laser photocoagulation in its descriptor, HCFA is instructing carriers to accept only code 67299 (unlisted procedure, posterior segment).

In a program memorandum issued in July, HCFA told carriers to require the use of CPT code 67299 instead of 67220 for PDT claims. The policy took effect July 1. New relative value units (RVUs) will be operative by 2002. HCFA is also planning to create several HCPCS codes for unilateral and bilateral PDT treatment for 2001.

HCFA has decided that PDT is an expensive treatment, and it will wait until a new code (with a lesser RVU) is created in November, instead of allowing ophthalmologists to code 67220. We have evaluated the recently approved ocular photodynamic therapy (OPT HCFAs name for PDT) procedures and believe that it is not comparable to laser photocoagulation, the HCFA memo states. Therefore, OPT must not be billed under CPT code 67220. Rather, carriers must require the use of CPT code 67299 (unlisted procedure) for claims for OPT.

The memo also instructs carriers that there is no national policy in place so coverage is to be determined at the carrier level. HCFA does, however, advise carriers to consider that 67299 includes Visudyne, the infusion and all other services required to perform PDT, excluding evaluation and management (E/M) services, fluorescein angiography (92235) or other ocular diagnostic services, even if performed on the same day.

HCFA announced that ophthalmologists must contact their local carriers to determine whether they should submit an invoice for the cost of the drug by far, the most expensive part of the procedure. HCFA will not reimburse separately for the drug because the manufacturer did not have it registered with the United State Pharmacopoeia (USP). What this technicality means is that it may ultimately be very difficult to bill for a drug which costs from $1,300 to $1,600 a dose. Look for a coverage policy from your carrier to determine whether or not you are supposed to submit an additional billing of J3490 (unclassified drugs) for the Visudyne.

The HCFA memo allows for billing of the drug with the J3490 when the procedure is performed in a hospital inpatient or outpatient setting if the drug is approved by the pharmacy and drug therapeutics committee of the medical staff of the hospital furnishing the drug, the memo says. Once there is an outpatient prospective patient system in effect, you will have to use C1360 for PDT and C1203 for Visudyne. The American Academy of Ophthalmology (AAO) is working to resolve this issue with the United States Pharmacopoeia, HCFA and to make sure Visudyne is registered with the USP by Jan. 1, 2001.

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Experimental Laser Procedures Another important subject addressed by the HCFA memo are other new laser procedures that have not been approved. The memo states that transpupillary thermal therapy (TTT), destruction of macular drusen by photocoagulation and photocoagulation (feeder vessel technique) remain experimental. Carriers were advised to instruct providers not to submit these claims for payment and to deny any such claims as experimental. Experimental procedures are not payable by Medicare and if performed should be paid by the patient after completing an advanced beneficiary notice.