Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist is going to start administering Macugen to treat wet age-related macular degeneration lesions. What's the best way to code this?


Delaware Subscriber


Answer: The American Academy of Ophthalmology has published guidelines for coding Macugen (pegaptanib sodium injection), which the FDA approved for age-related macular degeneration (AMD) patients in December 2004.

The AAO recommends the following codes:

Report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) for the injection itself.

If there is also a separately reportable office visit on the same day, you may report that with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.

Report J3490 (Unclassified drugs) for the drug, since there is not a specific HCPCS code for Macugen.

In the free-form text area of the CMS 1500 form (Box 19 for a paper claim or the "Narrative" field for EMC), note the name of the drug and the exact dosage given.
 
The payment limit for a 0.3-mg injection of pegaptanib sodium will be $1,054.70, according to the recently updated "2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs." To download this list, visit www.cms.hhs.gov/providers/drugs/asp.asp.

Medicare has not yet determined which ICD-9 codes will prove medical necessity for Macugen injections, but experts expect that the only covered code will be 362.52 (Exudative senile macular degeneration).