Ophthalmology and Optometry Coding Alert

Question: Should I be reporting J3490 for Avastin for all carriers, including Medicare? This is what I have always done and as long as I have the required information in box 19, I have had no problems. But someone told me that they use J3490 for Medicare and J9035 for other carriers and this is what I should be doing. Is it?

Kentucky Subscriber

Answer: Unfortunately, even though Avastin, a drug used to treat wet age-related macular degeneration (AMD), has had its own HCPCS code for years, Medicare carriers still don't all agree on how to code for the treatment. Some carriers (for example, Cahaba, the Part B carrier for Alabama, Georgia, and Mississippi) want the HCPCS code for Avastin, J9035 (Injection, bevacizumab, 10 mg). Others (such as National Government Services, carrier for Connecticut, Indiana, Kentucky, and New York) direct you to report J3490 (Unclassified drugs), and still others (such as Palmetto GBA) want providers to use J3590 (Unclassified biologics).

Rationale: 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, Palmetto says.

Good idea: Get your carrier's policy on reporting Avastin treatments in writing so you know which HCPCS code to report. Enter the phrase "Avastin for AMD" or "bevacizumab for AMD" into the claim's narrative field, National Government Services says.

Most carriers agree that, on the same claim, you should also report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure])for the drug's injection, as well as 362.52 (Exudative senile macular degeneration) to show medical necessity.

Documentation: You may also need to attach an invoice to the claim. If you don't, you may need to include the following in the narrative field:

• the names of the components of these preparations

• the amount of the drug

• the invoice price for the preparation

• the name of the pharmacy compounding the drug.

Keep a copy of the invoice in the beneficiary's medical record, available for review by the carrier, if requested. You may also need to submit information supporting a wet AMD diagnosis on appeal.

Records should include fluorescein angiography (92235, Fluorescein angiography [includes multiframe imaging] with interpretation and report) or a comparable diagnostic test, such as optical coherence tomography (92135, Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser] with interpretation and report, unilateral).

If your carrier does not yet have a local coverage determination (LCD) for Avastin, you should have the patient sign an ABN. Be sure to append modifier GA (Waiver of liability statement on file) to 67028, as well as to the appropriate HCPCS supply code.