Ophthalmology and Optometry Coding Alert

If you haven't adjusted to the Avastin switch to Q2024, procrastinating for once may keep you in the payment game.

Confusion abounded when CMS created Q2024 (Injection, bevacizumab, 0.25 mg), effective Oct. 1, 2009. You already had J9035 (Injection, bevacizumab, 10 mg) for bevacizumab (Avastin). Here's the inside scoop on what code to use, and -- surprise! -- your best option might be a third code.

CMS had implemented Q2024 with a payment of $7 on Oct. 1, creating a significant gap in Avastin payment for ophthalmology. The lower dosage amount (0.25 mg per unit) made Q2024 more appropriate for ophthalmologists who use smaller amounts. But their outcry about payment problems encouraged CMS to delete Q2024, bringing much cheering from oncology and ophthalmology coders alike.

In its reversal, CMS announced that, "Effective immediately, CMS no longer recognizes Healthcare Common Procedure Coding System (HCPCS) Code Q2024 Avastin for payment of non-outpatient hospital claims. Practitioners shall return to their previous reporting practice for small intraocular doses of Avastin furnished prior to Oct. 1. HCPCS Code Q2024 will be deleted as of Jan. 1, 2010, and, therefore, it will be removed from the Average Sales Price pricing file effective with the January 2010 Release."

Bottom line: For most carriers, in 2010, continue to use old faithful code J9035 for bevacizumab. CMS has assigned J9035 an average sale price (ASP) of $57.46.

Ophthalmologists use Avastin to treat age-related macular degeneration (AMD).AMD is the leading cause of blindness in people over 50, says Becky Zellmer, CPC, COTA, MBS, CBCS, medical billing and coding supervisor for Suby, Von Haden and Associates in Neenah, Wis. Neovascular AMD (also known as exudative or "wet" AMD) is marked by abnormal blood vessels growing in the back of the eye, which sometimes leak blood or fluid that causes blurred or distorted vision.

Unfortunately, Medicare carriers still don't agree on how to code for Avastin to treat wet AMD, Zellmer notes. Some carriers (for example, Cahaba GBA, the Part B carrier for Alabama, Georgia, and Mississippi) want the providers to use J9035. Others (such as National Government Services, carrier for Indiana, Illinois, Michigan, and Ohio) direct you to report J3490 (Unclassified drugs), and still others (such as Palmetto GBA in California) want providers to use J3590 (Unclassified biologics).

The amount might be at the heart of the generic versus unclassified code debate, notes Maggie M. Mac, CPC,CEMC, CHC, CMM, ICCE, director, Best Practices- Network Operations at Mount Sinai Hospital in New York City. Because J9035 represents a 10-mg dose, and the typical dose for an intravitreal injection to treat wet AMD is 1.25 mg, J3590 is a more accurate choice, according to Palmetto GBA.

Good idea: Get your carrier's policy on reporting Avastin treatments in writing so you know which HCPCS code to report. Some carriers may require additional information on the claim. For instance, National Government Services instructs providers to enter the phrase "Avastin for AMD" or "bevacizumab for AMD" into the claim's narrative field.

Most carriers agree on the CPT and ICD-9 codes you should use with Avastin. You should also report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the drug's injection. And code 362.52 (Exudative senile macular degeneration) shows the injection is medically necessary.

Don't worry, however, if you were ahead of the game using Q2024; you should still get paid on those claims. CMS has instructed Medicare contractors to reprocess any claims from physicians for Avastin administered in their offices that were paid based on the Q2024 code, if requested by the physician.

Medicare claims processing contractors should be posting information pertaining to the reversal on their Web sites to inform providers of this policy change, notes the American Academy of Ophthalmic Executives (AAOE). Check carrier Web sites for further details and instructions for full reimbursement.