Ophthalmology and Optometry Coding Alert

Follow these steps to ensure proper payment for drug injections.

Although many of your top-billed codes likely involve eye exams and surgeries, you shouldn’t discount HCPCS Level II codes and the impact drug injections can have on your practice’s bottom line.

Given the sheer volume of medications administered via intravitreal injection — anti-vascular endothelial growth factor (VEGF) agents, steroids, antimicrobials — to treat everything from age-related macular degeneration (AMD), diabetic retinopathy, and retinal vein occlusion to macular edema and infection, drug injections are a significant revenue generator. And that makes coding them a crucial coding skill to have.

If your physicians regularly provide drug injections to treat various ocular conditions, read on for some best practices and pointers that’ll help you report these services accurately every time.

Identify the Appropriate J Code

“Each medication has a HCPCS code used for coding and billing ... Most of the medications used for intravitreal injections are assigned a HCPCS code represented with a first character of J,” says Joy Woodke, COE, OCS, OCSR, director of coding & reimbursement at the American Academy of Ophthalmology.

Each J code’s descriptor includes the route of administration, drug name, and dosage amount, which is the billable unit for that code. Typical ophthalmology examples include J0178 (Injection, aflibercept, 1 mg) for Eylea and J2778 (Injection, ranibizumab, 0.1 mg) for Lucentis, two commonly used anti-VEGF agents.

Verify Single-Use or Multidose Vial

Many frequently used ophthalmic drugs are distributed as prefilled syringes (i.e., Eylea), while others may be purchased in single-dose (i.e., Vabysmo, Byooviz) or multidose vials (i.e., Kenalog). To ensure proper reporting, providers should identify the injectable drug’s number of units and whether billing for wastage is appropriate.

For single-use vials, bill the units injected with the appropriate J code, along with any wasted medication greater than one unit. When billing for wasted medication, submit the same J code on a second line and append modifier JW (Drug amount discarded/ not administered to any patient). On the other hand, when the drug is obtained from a multidose vial, only the units injected are billed.

“Modifier JW applies to single-use vials of medication, not multi-use vials, and documentation is key,” explains Jennifer M. Connell, CPC, COC, CENTC, CPCO, CPMA, CPPM, CPC-P, CPB, CPC-I, CEMA, CEMC, owner of E2E Health Solutions in Victoria, Texas. More specifically, when considering what drugs and biologicals are eligible for modifier JW use, you must first confirm that the drugs are designated as “single-use or single dose on the FDA-approved label or package insert,” according to Medicare guidelines.

Be sure to check the medication vial label to identify the corresponding National Drug Code (NDC) and report it on the CMS-1500 (in either box 19 or the shaded area of box 24, depending on payer guidelines) or Electronic Data Interchange (EDI) equivalent.

“NDC numbers may originate as a 5-3-2 or 4-4-2 format. Although the NDC is a 10-digit number, most insurance carriers require a conversion to a 5-4-2 format, totaling 11 digits. To convert to the 5-4-2 format, a zero is added to the [beginning of the] appropriate segment,” notes Woodke.

Give Compounded Drug Details if Using Unlisted Code

Many payers prefer the unlisted J codes (J3490 or J3590) when medication is compounded at a pharmacy into a single-dose syringe. When your physician uses these, the description of the medication and dosage should be indicated in box 24a of the CMS-1500 form or EDI loop 2410.

For instance, bevacizumab (Avastin) is a compounded drug when used in ophthalmology. So before submitting a claim for these injections, check the policy, as the payer may have a preferred J code. Coding options for bevacizumab include:

• J9035 (Injection, bevacizumab, 10 mg),
• J3490 (Unclassified drugs),
• J3590 (Unclassified biologics), and
• J7999 (Compounded drug, not otherwise classified).

Note: If there is no expense to the physician for the drug (i.e., sample drug or specialty pharmacy), don’t submit for payment.

Understand ASP and Calculating Units

Each drug is assigned a payment limit, or allowable, and the HCPCS dosage is confirmed on the CMS average sales price (ASP) drug pricing published spreadsheet (www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/asp-pricing-files). Because the ASP is adjusted quarterly, it is crucial to monitor updates to the payment limits.

When determining how many units of a drug to report, always check the documentation and pinpoint the amount of drug injected. Then identify the appropriate J code for each medication and calculate how many units of the drug the injection represents based on the dosage in the description. The dosage per the HCPCS Level II code descriptor is the minimum dosage and is considered one unit.

Then use the following rules to figure out how many units to bill:

• If the dose injected is the same as the dose in the descriptor, bill one unit.
• If the dosage is more than the code descriptor, divide the amount administered by the minimum dosage.
• If the dosage is less than the code descriptor for one unit (minimum dosage), bill one unit.

For example, coding an injection of ranibizumab 0.3 mg — the descriptor indicates a minimum dosage of 0.1 mg. Dividing 0.3 mg (amount injected) by 0.1 mg (minimum dose) gives you three units to be submitted. Note that this dosage is a single-use vial but does not have wastage greater than one unit, so no wastage would be billed. Thus, you would bill the medication as J2778, 3 units x $173.378 = $520.13 total reimbursement.

Note: “The payment limit per the CMS ASP drug pricing is the allowable for Medicare Part B claims. For commercial, Medicare Advantage, and Medicaid payers, reimbursement may be based on your contract. Some payers may calculate it as a percentage of the CMS ASP pricing or of your usual and customary fee,” according to Woodke.