ASC Adviser

Reimbursement Considerations for DSEK and DLEK

By Mary Pat Johnson, COMT, CPC, COE, and Kevin J. Corcoran, COE, CPC, FNAO

Keratoplasty is a general term used for several corneal procedures such as penetrating corneal transplants and refractive surgery. A newer form of keratoplasty known as Desemet's stripping endothelial keratoplasty (DSEK) or deep lamellar endothelial keratoplasty (DLEK) is generating plenty of discussion among cornea specialists.

From a surgical perspective, the procedure involves a small incision in the cornea through which the strips away diseased or endothelial corneal cells. stripping, harvested endothelium from a donor cornea is placed on the inner surface of the recipient cornea. The patient's compromised cornea clears rapidly once the new endothelium begins to function and the common postoperative problems of penetrating keratoplasty (PK) related to sutures and astigmatism are avoided.

Reimbursement Controversy

When new technology or procedures are introduced to the field of medicine, they are often met reimbursement roadblocks. In particular, lack of a specific CPT code report the procedure on a claim necessitates use of a CPT code, causing administrative headaches. Furthermore, new procedures are seldom the topic of coverage and payment policies, leaving providers in reimbursement limbo.

DSEK and DLEK are prime examples of the quandary engendered by an exciting new procedure. Until recently, many cornea surgeons reported them as PK although there is little similarity to the surgical approach of traditional PK. also, these new procedures are popular despite the dearth of any regulatory policies by Medicare and other third-party payers. So, when DSEK and DLEK grew in number the point that they could no longer hide under the radar, controversy erupted. Some Medicare carriers have published tough new policies that restrict or end payment for them.

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Indications

DSEK or DLEK are not considered for all corneal pathologies, rather they are indicated for corneas with endothelial dysfunction. In cases of anterior corneal disease, such as central corneal opacity (ICD-9 371.03), keratoconus (ICD-9 371.6x) or anterior pigmentation of cornea (ICD-9 371.11) a penetrating or lamellar keratoplasty may be preferred.

Existing CPT Codes

CPT currently includes several choices to report keratoplasties. existing codes include:

65710 keratoplasty (corneal transplant); lamellar

65730 penetrating (except in aphakia)

65750 penetrating (in aphakia)

65755 penetrating (in pseudophakia)

65767 epikeratoplasty

Not one of these codes precisely describes DSEK or DLEK. To remedy this problem, we anticipate that an application for a new CPT code will be made. What should be done in the meantime?

Close Enough Isn't Enough

In the introduction of the CPT handbook, the user is given instructions about selecting an accurate code to report the service on a claim for reimbursement. Some services performed by providers are not found in the CPT coding system. These services or procedures may be new procedures that have not yet been assigned a CPT code or simply a variation of a procedure that precludes using the existing CPT code.

Each section of the CPT coding system includes codes for reporting these unlisted procedures. Unlisted procedure codes should not be coded unless the coder has reviewed the CPT coding system carefully to ensure that a more specific code is not available. If a specific CPT code is not located, check for HCPCS codes may be reportable.

Users are not permitted to select a CPT code that merely approximates the service provided; there is no thing as "close enough" coding. Within the section for Surgery of the Eye and Ocular Adnexa, there are seven unlisted procedures, including CPT 66999 (unlisted surgical procedure on anterior segment). For the present, it is the best code to describe DSEK or DLEK.

Even so, the Medicare program doesn't always follow the instructions in CPT. Two Medicare carriers have published instructions to report DSEK procedures using PK codes (CPT 65730 - 65755). In October 2006, Wisconsin Physicians' the Medicare carrier for Illinois, Michigan, Minnesota and Wisconsin, published the following instruction:

"For Medicare Part B, the new Descemet's stripping procedure may be adequately coded as 65730, 65750 or 65755 (based on the patient's lens status), until such time as a more specific code is released. Coding with an unlisted procedure code such as 66999 is not incorrect, but will trigger delays for additional documentation requests, processing, review, and crosswalking of reimbursement."

In December 2006, NHIC Medicare published the same instruction for providers in its New England region. This is welcome news to providers in those areas since the use of an existing CPT code often simplifies the claims processing and allows for faster reimbursement than using an unlisted procedure code.

However, Trailblazer Health took a very different point of view. On April 23, 2007, the Trailblazer Web site included the following instruction.

"Use of DSLEK/DSAEK results in significantly shorter healing time and is covered by Medicare. Providers should bill DSLEK/DSAEK with CPT NOC code 66999 (unlisted procedure, anterior segment of eye). It is suggested that for Part B carrier claims, the operative report be submitted with the claim to help expedite claim payment. CPT code 65730 (keratoplasty, lamellar, penetrating) should NOT be used to bill for DSLEK/DSAEK."

Noridian Medicare has taken an even more restrictive stance. Their website contains a draft LCD addressing Non-Covered Services that lists DSEK as experimental or investigational and therefore non-covered.

With only two Medicare carriers advocating the use of the PK codes, most providers are obliged to use CPT 66999 to identify DSEK procedures.

Physician Reimbursement

Under the Medicare Physician Fee Schedule, no RVUs are assigned to miscellaneous codes. Physician reimbursement is at the discretion of the carrier on a case-by-case basis. Payment of one claim does not establish a precedent for the next. Additional documentation, such as an operative report, is usually required for claim processing. At the end of the dictation, it is a good idea to describe a comparable procedure, such as PK, that may be used to determine a fair reimbursement.

HOPD Facility Fees

Under Medicare's Outpatient Prospective Payment System (OPPS), CPT code 66999 has been assigned to APC-232 for the hospital outpatient department (HOPD) and the allowed amount for 2007 is $373.

ASC Facility Fee

Currently, ASCs may only receive reimbursement for eligible procedures that meet certain guidelines for safety, the length of the surgical procedure and the pre- and postop recovery time. At this time, CPT code 66999 is not eligible for an ASC facility payment. CMS has proposed substantial changes to its payment methodology for ASCs beginning in 2008.

Tissue Reimbursement

For hospitals, the Medicare Claims Processing Manual Chapter 4 §200 states, "Corneal tissue will be paid on a cost basis, not under OPPS. To receive cost-based reimbursement hospitals must bill charges for corneal tissue using HCPCS code V2785." The invoice to the HOPD from the eye bank will reflect the handling for harvesting corneal tissue as well as any additional processing of the tissue to prepare the endothelial graft.

Getting an ABN for Non-covered Procedures

For providers practicing in Noridian's jurisdiction, or wherever DSEK and DLEK are considered to be investigational and experimental, the entire procedure is ineligible for reimbursement. Patients should be made aware of their financial responsibility for the professional fees, facility fees and tissue costs. Obtain a signed ABN prior to surgery to document the patient's acceptance of this financial responsibility.

Conclusion

DSEK and DLEK offer clinical advantages over penetrating graft procedures, such as faster recovery time and reduction of postoperative astigmatism and complications. Nevertheless, early adopters face some reimbursement hiccups. Until a unique CPT code is assigned with its own RVU value, coding for this procedure defaults to a miscellaneous CPT code, 66999. Two Medicare carriers disagree and have published instructions that permit use of PK codes. Check your local policies frequently for anything new from your carrier, as this is an evolving area in reimbursement. New codes and new payment instructions are anticipated to resolve this controversy. OM