Ophthalmology and Optometry Coding Alert

Don't give up on AK payments if you can prove that astigmatism is surgically induced

If you assume that Medicare will deny any procedure that reshapes the cornea as cosmetic, you could be denying your practice over $450 in legitimate reimbursement.

Ophthalmologists today have plenty of options for surgically remodeling the cornea. Although corneal remodeling is often performed to correct refractive error, Medicare and private insurers do consider it medically necessary in some cases. Successful claims depend on knowing why the surgeon performed the procedure.

Look for Surgically Induced Astigmatism for AK

Astigmatic keratotomy procedures use two different methods to reshape the cornea to reduce astigmatism. The ophthalmologist may use a corneal relaxation incision or a corneal wedge resection to alter the curvature of the cornea. Ophthalmologists will sometimes also perform AK at the time of cataract surgery to correct pre-existing astigmatism.

Problem: Many insurers, including Medicare, will only cover AK if the patient's astigmatism is iatrogenic (caused by prior surgery, such as cataract surgery or cornea transplant), says Janice Douglas, CPC, coder for the department of ophthalmology at the Medical College of Georgia in Augusta. Also, note that the CPT codes for AK specify that the astigmatism must be surgically induced:

• 65772--Corneal relaxation incision for correction of surgically induced astigmatism

• 65775--Corneal wedge resection for correction of surgically induced astigmatism.

Medicare assigns 10.04 nonfacility RVUs to 65772, leading to $380.49 in reimbursement (unadjusted for geography) after multiplying by the 37.8975 conversion factor. The same formula yields $455.90 from the 12.03 facility RVUs assigned to 65775.

Additionally, individual carriers may have guidelines regarding how much the patient's astigmatism must have increased to warrant the surgery. Policies for coverage typically require a change of 2-2.5 diopters from the patient's presurgical state to after.

Among the ICD-9 codes many insurers will accept to prove the medical necessity of the procedure are:

• 367.20-367.22--Astigmatism

• 996.51--Mechanical complication due to corneal graft

• V42.5--Organ or tissue replaced by transplant; cornea

• V45.61--Cataract extraction status.

Pre-existing astigmatism: Because 65772 and 65775 can only be used to treat iatrogenic astigmatism, if the patient's astigmatism is not surgically induced, report 66999-GA (Unlisted procedure, anterior segment of eye; waiver of liability statement on file), Douglas says. In Item 19 of the CMS-1500 form (or its electronic equivalent), put a description of the procedure--for example, "corneal relaxation incision to correct pre-existing astigmatism."

If the ophthalmologist plans to perform AK at the time of cataract surgery, you cannot code separately for it, since NCCI bundles 65772 and 65775 into cataract procedures 66982-66984, says Cindy Mundy, CCS-P, coder and abstractor for the UC Davis Medical Center.

Inform the patient that Medicare will not cover the AK due to the reason for the surgery. Since this procedure is sometimes covered for Medicare-approved diagnoses, it would be necessary to obtain an advance beneficiary notice (ABN) specifically explaining to the patient that the procedure will not be covered for non-surgically induced astigmatism or "pre-existing" astigmatism and append modifier GA to the code, says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. 

Report PTK HCPCS Code to Non-CMS Carriers

Phototherapeutic keratectomy (PTK) uses an excimer laser to remove damaged or diseased tissue from the central anterior surface of the cornea. Medicare will sometimes cover PTK; Part B carrier Noridian's policy specifies that the excimer laser is acceptable for:

• treating an area up to 300 microns thick or a cornea at least 250 microns thick after ablation, when other less invasive procedures (such as stromal puncture, CPT code 65600) are not possible or have failed.

• treating anterior corneal dystrophies, scars and other opacities, and smoothing irregular corneal surfaces to improve acuity, reduce pain, or help the patient better tolerate spectacles or contact lenses.

Procedure: For Medicare patients, you will need to report unlisted anterior segment procedure code 66999, just as you would for non-iatrogenic AK, Douglas says. Indicate "PTK by excimer laser" in Item 19 on the CMS-1500 form.

Some non-Medicare carriers, such as Blue Cross/Blue Shield, want you to report HCPCS code S0812 (Photo-therapeutic keratectomy), a temporary national code not covered by Medicare.

Diagnosis: Noridian lists the following ICD-9 codes as the only covered codes for PTK:

• 367.22--Irregular astigmatism
• 370.62--Corneal neovascularization; pannus (corneal)
• 371.00-371.03--Corneal scars and opacities
• 371.42-371.44--Corneal degenerations
• 371.46--Nodular degeneration of cornea
• 371.50--Hereditary corneal dystrophy, unspecified
• 371.52--Other anterior corneal dystrophies.

Watch out: Do not confuse PTK with PRK, photorefractive keratotomy--even though, technically, they are the same procedure. Aetna's clinical policy bulletin specifies that PTK is used to correct particular corneal diseases, "whereas PRK involves the use of the excimer laser for correction of refraction errors (e.g., myopia, hyperopia, astigmatism and presbyopia) in persons with otherwise non-diseased corneas."

Medicare will not cover PRK at all, Douglas says. If you need to send a claim to Medicare, report 66999-GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit), with a description in Item 19 of the CMS-1500 form.

"Submitting a claim to Medicare for services that are always non-covered is done at the request of the patient or to obtain a denial in order to submit to a secondary insurance," Mac says. "Otherwise, submitting non-covered services to Medicare is not necessary and the patient is responsible for payment of the service."