Ophthalmology and Optometry Coding Alert

Now that coding and payment policies for ocular photodynamic therapy (OPT) (67221, destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) are in place for treating classic lesions, the next hurdle is reimbursement for treating occult lesions. The FDA has not yet approved Visudyne, the medication used in OPT, for treating occult lesions in age-related macular degeneration (ARMD), so Medicare wont cover those indications. Until CMS issues and implements a national coverage policy, before treating a patient with OPT for occult lesions in ARMD, obtain a signed advance beneficiary notice to collect the fee from the patient.
 
The FDA approved Visudyne for treating classic lesions of ARMD and is expected to approve it for treating occult lesions in the future. Medicare covers only approved treatments.
 
Occult lesions are an earlier stage of choroidal neovascularization than the classic ARMD, explains Kitty Timmes, COMT, office manager for retinologist Joseph J. Timmes, Jr., MD, FACS, of Annandale, Va. The progress of occult lesions is slower, but the indications for treatment are very similar.

Iffy Diagnosis Code  
There is no ICD-9 code for occult lesions, only a generic diagnosis code which can apply to classic or occult lesions: 362.52 (exudative senile macular degeneration [wet disciform]). The diagnosis definition doesnt specify whether the lesions are classic or occult.
 
Since Medicare doesnt pay for treatment that is not approved by the FDA, you have only one ethical coding choice: dont bill OPT for occult lesions until it is approved. It is absolutely fraudulent to bill for a treatment that is not FDA approved yet, says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses. Tell the patient, This is not approved by the FDA so Medicare wont pay, and if you want it you must pay out of your pocket.
 
Do not bill Medicare, even though there is an iffy diagnosis code available, until the technology is approved for this application, Roberts says. If you do, and an auditor discovers the patients fundus angiograms show occult lesions, the money would have to be refunded and fines or worse may be incurred.