Ophthalmology and Optometry Coding Alert

With all the confusion about coding for photodynamic therapy (see Optimize Reimbursement for Photodynamic Therapy on page 57), its unavoidable that there will be confusion about coding for transpupillary thermal therapy (TTT) as well. That confusion could lead you to file fraudulently.

The code in question 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization], one or more session, photocoagulation [e.g., laser, ocular photodynamic therapy]) is not supposed to be used for TTT, but for photodynamic therapy (PDT). You should use 67299 (unlisted procedure, posterior segment) for TTT. The Health Care Financing Administration (HCFA), the American Academy of Ophthalmology (AAO) and local Medicare carriers, say you must use 67299 for TTT because this treatment is experimental. It is currently in trials.

If you report 67220 when you performed TTT, then you are saying that you performed a covered procedure, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based coding, reimbursement and compliance consulting firm specializing in ophthalmology.

With an unlisted code, you will always need to file a paper claim with much documentation. You will have to wait much longer for payment, and there is a good chance that the person who processes your claim will not be familiar with all of the explanations involved, and will reject it, so you will have to appeal. There is much to be said for avoiding the unlisted code, and that's why so many ophthalmologists are tempted to do so. In this case, however, the unlisted code is the only one that you can use using another code would be inaccurately representing the service.

Some ophthalmologists are reporting 67220 and getting paid for it, but thats because the insurer doesnt know what was actually done. An audit would reveal that you billed for an experimental procedure as if it were a covered procedure, and you would have to refund the money and perhaps pay a fine. If there were any indication of a pattern of this kind of fraudulent filing, you could even be prosecuted. That is why, says Duran, ophthalmologists should bill 67299 for TTT.




PDT and TTT Differences

Photodynamic therapy (PDT) and transpupillary thermal therapy (TTT) are similar procedures, but they should not be coded the same. Use code 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization], one or more session, photocoagulation [e.g., laser, ocular photodynamic therapy]) for PDT and 67299 (unlisted procedure, posterior segment) for TTT. Here are the differences between the two treatments:

Different lasers. There are two different kinds of lasers used. The laser for TTT is only $35,000 much less than the laser used for PDT (approximately $80,000). This may partly explain why errantly using 67220 to bill TTT is so common many [...]