Ophthalmology and Optometry Coding Alert

Question: I was wondering if there is any way to bill for the use of mitomycin C during a pterygium excision. We do not perform a graft; instead, we apply mitomycin C, which takes additional operating time and has added risk of complications such as corneal or scleral melt.

Anonymous Alaska Subscriber

Answer: A pterygium is a growth on the conjunctiva that can advance onto the cornea, requiring removal. If it is removed and then mitomycin C, an anti-cancer drug, is applied, the recurrence of a pterygium after surgical excision can sometimes be prevented. The code for an excision without a graft, as the reader describes, is 65420 (excision or transposition of pterygium; without graft); with a graft, the code is 65426. If the ophthalmologist chooses to use mitomycin C instead of a graft, there is no special procedure code.

The cost of the drug itself is included in the procedure, just as it would be if you were using the medication for a trabeculoplasty. Using mitomycin C to prevent pterygium recurrence is an unlabeled use of the drug. Although the Food and Drug Administration generally does not interfere with physicians decisions concerning how to treat patients, Medicare and many private payers are cautious regarding paying for off-label uses of medications.

Medicare does say, however, that off-label uses may be covered if the carrier determines the use to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. Mitomycin C is indicated for the treatment of cancer and is injected intravenously under the recommended indications.

Pterygium is not cancer. Consequently, you may need to get appropriate approvals from the carrier. The HCPCS codes for mitomycin C are J9280 for 5 milligrams, J9290 for 20 milligrams and J9291 for 40 milligrams.