Ophthalmology and Optometry Coding Alert

Also: Follow carrier rules for Avastin treatments -- or risk losing $57 a dose Good news for ophthalmology coders: Two popular drugs to treat wet AMD finally have their own HCPCS codes. The bad news: In some cases, you may still have to report them with "unclassified" codes -- or face denials. Since the FDA approved ranibizumab injections (Lucentis) to treat wet age-related macular degeneration (AMD) in 2006, ophthalmologists have been increasingly using the drug. Previously, coders had to resort to an "unclassified" code to report Lucentis -- but that all changed in 2008. However: If your practice uses bevacizumab to treat wet AMD, you may still have to use that "unclassified" code -- even though the drug (trade name Avastin) has had its own HCPCS code for years. Start Using New J Code for Lucentis The FDA approved Lucentis on June 30, 2006, to treat neovascular (also known as "exudative" or "wet") AMD, in which abnormal blood vessels grow behind the macula. Code 362.52 (Exudative senile macular degeneration) describes this condition, says Diane McVinney, CPC, billing manager at the Jones Eye Institute at the University of Arkansas for Medical Sciences in Little Rock. Wet AMD usually progresses from non-neovascular, or "dry" AMD (362.51, Nonexudative senile macular degeneration), which is the more common condition. Depending on the nature of the neovascularization, an ophthalmologist may further classify wet AMD as either classic or occult. Nonetheless, you would use 362.52 to describe either form. New code: Effective Jan. 1, 2008, you can report Lucentis treatments with a new permanent HCPCS code, J2778 (Injection, ranibizumab, 0.1 mg), McVinney says. Previously, carriers directed coders to report J3490 (Unclassified drugs) or J3590 (Unclassified biologics) for the drug supply, she says. For the indicated single Lucentis dose, 0.5 mg, report five units of J2778. On the same claim, report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection of the drug. Most insurers will only accept 362.52 to prove medical necessity for an intravitreal Lucentis injection. If your provider injects both eyes, report 67028 with modifier 50 (Bilateral procedure), says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley and Associates in Clearwater, Fla. "Alternatively, you may report 67028 with modifiers LT and RT on two lines," she says. CMS placed the average sale price (ASP) of a 0.1-mg dose of ranibizumab at $408.887. Medicare reimburses drugs at the ASP plus 6 percent, making the payment for five units of J2778 $2,167.10. Code 67028 pays approximately $193.10 (5.07 transitional total nonfacility relative value units [RVUs]), using the 2008 Medicare Physician Fee Schedule and a conversion factor of 38.0870 for services performed in the physician's office. Reimbursement for bilateral injections will be [...]