Ophthalmology and Optometry Coding Alert
Cross the Vast Avastin Coverage Gap
New Jersey Subscriber
Answer: Although local policies may vary, Medicare generally will not reimburse for the use of bevacizumab (Avastin) to treat age-related macular degeneration. Avastin is primarily used to treat colon or rectal cancer; intravitreal injections to treat AMD are off-label, and Medicare considers it investigational. Explain this to your patient, and have him sign an advance beneficiary notice (ABN) before you start treatment.
For the injection, report 67028-GA (Intravitreal injection of a pharmacologic agent [separate procedure]). This is the same code you would report for an injection of Macugen or Kenalog.
For the Avastin supply, you will need to report J3490-GA (Unclassified drugs), since there is no HCPCS code for Avastin yet. Append modifier GA (Waiver of liability statement on file) to both codes to show that the patient has signed an ABN.
Don't miss: Enter "Avastin (or bevacizumab) for macular degeneration" in Item 19 or the comments area of the CMS-1500 claim form.
Related news: Starting Jan. 1, 2006, there is a new HCPCS code for Macugen. Report J2503 (Injection, pegaptanib sodium, 0.3 mg) for the supply. See "Welcome New Codes for Singh Filtration, Anti-Angiogenic Therapy" in the December 2005 issue of Ophthalmology Coding Alert for more information.
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