Optometry Coding & Billing Alert

Published on Mon Aug 10, 2015 PDF

Optometrists have a crucial role in the care of age-related macular degeneration patients, and proper coding will help bring in deserved reimbursement.

By 2050, there will be 5.44 million people with age-related macular degeneration (AMD), one of the leading causes of blindness in the U.S., according to the National Eye Institute. Which means that if your practice is now seeing its share of AMD patients, it’s bound to start seeing more soon as the trend continues upward.

It also means that if you have questions about how to code and bill AMD services correctly, now’s the time to get them answered. Read on for some frequently asked questions about AMD.

Question: If several tests are necessary to diagnose wet AMD, can I bill for them separately?

Answer: When your optometrist suspects AMD, he’ll complete several tests to confirm the diagnosis. Some are as simple as a dilated eye exam, visual acuity test, or fundoscopy. He might also complete a fluorescein angiography if he suspects a patient might have wet AMD. These can all be done on the same day, but it would be unlikely due to the amount of time that a fluorescein angiography takes to perform, experts note.

Performing all the diagnostic tests on the same day, however, doesn’t mean they’re separately billable. Visual acuity and fundoscopy are part of the eye exam or E/M, and are not separately billable. Fluorescein angiography (CPT® code 92235) is separately billable per eye when pathology is present.

Bilateral billing is allowed with 92235, with full payment for each eye, either on one line with modifier 50 (Bilateral procedure) or on two lines with modifiers LT (Left side) and RT (Right side) appended, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

Question: What’s the difference between the AMD diagnosis codes?

Answer: The diagnosis code you report depends on the type of AMD present in the patient.

Background: Macular degeneration occurs when the small central portion of the retina, known as the macula, deteriorates. It can be diagnosed as either dry or wet AMD.

Dry: If the patient suffers from nonexudative – otherwise known as dry or atrophic – senile (age-related) macular degeneration, report ICD-9 code 362.51 (Nonexudative senile macular degeneration of retina) before Oct. 1, 2015. After that date, the ICD-10 codes take effect, and you would report H35.31 (Nonexudative age-related macular degeneration). In dry AMD, yellowish cellular debris called drusen accumulates, which can cause atrophy and scarring to the retina. Dry AMD is more common and less severe, but can lead to the more severe wet AMD.

Wet: If the patient suffers from exudative – also known as disciform or wet – senile macular degeneration (sometimes called Kuhnt-Junius degeneration), report ICD-9 code 362.52 (Exudative senile macular degeneration of retina). After Oct. 1, 2015, report ICD-10 code H35.32 (Exudative age-related macular degeneration). In wet AMD, which is more severe than the dry form, blood vessels grow behind the retina, leaking blood and fluid.

Wet AMD falls into two categories: occult and classic. Whichever the category of wet AMD, however, the diagnosis code would still be 362.52 or H35.32.

Question: What are the treatments for AMD? Are any within the optometrist’s scope of practice?

Question: Although certainly historically more common, injectables done by a retinal specialist (to whom the optometrist refers the patient after detecting AMD) are not the only option. Some ophthalmic practices are offering a tiny (pea-sized) telescope manufactured by CentraSight, implanted behind the iris to project images onto the non-degenerated portions of the patient’s macula. The telescope enlarges the image, reducing the patient’s blind spot.

Approved in 2010, the telescope insertion still only has a temporary CPT® code: 0308T (Insertion of ocular telescope prosthesis including removal of crystalline lens). Individual carriers price the code; there is no national reimbursement rate.

In an ASC or hospital outpatient department, the ophthalmologist would report HCPCS code C1840 (Lens, intraocular [telescopic]) for the supply of the device. While Medicare does not make separate payment for most devices described by C codes, CMS expects hospitals to accurately report and code procedures and report C codes when applicable.

More commonly, an ophthalmologist will turn to one of the following injectable anti-vascular endothelial growth factor (VEGF) agents for their AMD patients, reported with these HCPCS codes for the supply:

• Lucentis: J2778 (Injection, ranibizumab, 0.1 mg)

• Eylea: J0178 (Injection, aflibercept, 1 mg)

• Macugen: J2503 (Injection, pegaptanib sodium, 0.3 mg)

The doctor would also report 67028 (Intravitreal injection of a pharmacologic agent [separate procedure]) with modifier LT, RT, or 50 (Bilateral procedure) for the injection.

The ophthalmologist may also opt to treat AMD with photodynamic therapy, using the drug Visudyne. Instead of an ocular injection, Visudyne is given through an intravenous injection in the arm, then activated by light in the eye.

Report CPT® code 67221 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) for the procedure; HCPCS code J3396 (Injection, verteporfin, 0.1 mg) for the drug.

For a small percentage of patients, the ophthalmologist may choose laser photocoagulation – CPT® code 67210 (Destruction of localized lesion of retina [e.g., macular edema, tumors], 1 or more sessions; photocoagulation).

On the horizon: A topical drug in eye drop form, Squalamine, manufactured by Ohr Pharmaceutical, is currently in FDA testing as a treatment for wet AMD