coding & reimbursement
Intacs For Keratoconus
Under what circumstances is the procedure reimbursed?

By Suzanne L. Corcoran, C.O.E.

Intacs have been marketed for a number of years, but have just recently been FDA approved for the treatment of keratoconus. This column discusses the specifics of reimbursement for this application.

Q: How are Intacs used in the treatment of keratoconus? Intacs were approved by the FDA in 1999 for treatment of mild myopia and astigmatism. In July 2004, the manufacturer received a Humanitarian Device Exemption for the use of Intacs to treat keratoconus in patients who no longer achieve adequate functional vision with contact lenses or eyeglasses. This procedure helps to restore functional vision and potentially defers the need for a corneal transplant procedure.

Surgical treatment of keratoconus with Intacs is reversible and less invasive than penetrating keratoplasty (PK). Recovery time is faster, and the cost is considerably lower. Patients may even be able to wear contact lenses again. PK at a later time is not precluded, if it becomes necessary.

Q: Is this procedure covered by insurance? It depends on the reason for the procedure. Most insurance plans do not cover cosmetic refractive surgery. For patients with keratoconus who can still obtain functional vision with contacts or eyeglasses, but prefer not to wear them, this procedure would be considered refractive. However, when keratoconus has progressed to a point where keratoplasty is seriously considered as a viable option, the procedure may be covered. We advise requesting prior authorization from the payer. Since the use of Intacs for keratoconus is so new, it is useful to include a detailed explanation of the procedure with the claim. Sometimes, a phone call between the surgeon and the insurer�s medical director can be helpful, since it offers the surgeon an opportunity to describe the patient�s condition and alternative therapies �doctor-to-doctor.�

Q: What code is used to describe implantation of Intacs? There is no specific CPT code for this procedure, so 66999 (unlisted procedure, anterior segment of the eye) has been the only alternative. However, this year the American Medical Association issued a new Category III code to describe the procedure, 0099T (implantation of intrastromal corneal ring segments). This code is effective as of July 1, 2005. Although a Category III code does not have associated RVUs or a fee schedule amount, use of the new code will help identify the procedure as distinct. With any luck, this will pave the way for a regular CPT code.

Through June 30, doctors should use the 66999 code. Starting on July 1, doctors should use 0099T. The codes do not overlap, and it is certainly possible that not all payers will accept the new 0099T code right away.

Q: Do we get reimbursed for the Intacs implants? Implantation of Intacs is usually performed in an ambulatory surgery center or hospital outpatient department. In these cases, the facility will purchase and then be reimbursed for the implants. In the special case where the procedure is performed in a physician�s office, the physician may request reimbursement.

There is no specific healthcare common procedure coding system to describe Intacs, so a miscellaneous code (L8699, prosthetic implant, not otherwise specified) is used. As with the claims for the surgeon and facility fee, information about the implants should accompany the claim. This information should include a description of the product, the purpose of the implants, FDA approval status and an invoice showing acquisition cost. It may also be helpful to include Centers for Medicare and Medicaid Services� (CMS) regulations regarding additional payment for prosthetic devices. While private insurers aren�t required to follow CMS rules, they often do.

New devices and surgical procedures often take time to become readily accepted by insurance companies, so practices and facilities often have a difficult time obtaining reimbursement. As time goes on, and more payers recognize the benefits of new procedures, the reimbursement picture improves. In the case of Intacs, We are still in the early stages of educating the payers.

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.