Coding & Reimbursement

Insights on Coding DSEK

By Suzanne L. Corcoran, COE

New surgical procedures are being developed all the time, to the advantage of surgeons and patients. One of particular interest is known as DSEK, or DSAEK. Here are the coding basics you need to know about it.

Q. What is DSEK/DSAEK?

A. Descemet's stripping endothelial keratoplasty (DSEK) or Descemet's stripping automated endothelial keratoplasty (DSAEK) are interchangeable terms for a newer form of corneal transplantation that replaces just the posterior diseased cornea, leaving the corneal surface relatively untouched. The procedure in-volves a small incision in the cornea through which the surgeon strips away diseased or opacified corneal endothelial cells and grafts the posterior ¼ to ⅓ donor cornea thickness to the inner surface of the recipient cornea.

DSEK/DSAEK is indicated for corneal endothelial dysfunction, including Fuchs' dystrophy (371.57) and bullous keratopathy (371.23). In cases of anterior corneal disease, such as central corneal opacity (371.03), keratoconus (371.6x), or anterior pigmentation of cornea (371.11), a penetrating or lamellar keratoplasty may be preferred.

DSEK/DSAEK is not indicated for elective refractive surgery.

Q. Does Medicare cover this procedure?

A. Yes, when indicated. Corneal transplantation, by whatever means, has not been a problem from a coverage policy standpoint. Medicare's coverage policies have very little to say about DSEK/DSAEK at this time.

Q. How is the procedure billed?

In 2009, there are two new CPT codes:

65756: Keratoplasty (corneal transplant); endothelial

+65757: Backbench preparation of corneal endothelial allograft prior to transplantation (list separately in addition to code for primary procedure).

For the surgeon, the first code is always used. The second, add-on code (+), only applies if the surgeon also performs the lamellar dissection of the donor tissue. If that work is done at the Eye Bank, the surgeon does not charge for backbench preparation. Trephination or punch does not qualify as 65757.

For 65756, the 2009 national Medicare Physician Fee Schedule amount for participating providers is $911.11. This is adjusted by local wage indices. No payment rate is published for the backbench work; payment for 65757 is determined by the Medicare administrative contractor on an individual basis.

Medicare assigns a global surgery period of 90 days for 65756; there is no global period for 65757.

Q. What about payment for the facility?

A. In an ASC, the 2009 Medicare facility payment for 65756 is $1,532.41, compared with $1,251.32 for all other keratoplasties. In the hospital outpatient department, the 2009 Medicare facility payment for ambulatory payment classification 0244, which includes 65756, is $2,508.02. There is no facility fee for 65757 in either location.

Q. How is the tissue reimbursed?

A. 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 [or ASCs] must bill charges for corneal tissue using HCPCS code V2785." The invoice to the facility from the Eye Bank will reflect the handling charges for harvesting corneal tissue as well as any additional processing of the tissue to prepare the endothelial graft.

Q. What happens if there is an immediate postoperative pressure spike? Is the postoperative visit billable?

A. No. An IOP spike is a known complication in a very small percentage of patients. Medicare global surgery rules state that medical management of complications during the postoperative period, which do not require a return to the operating room, are included in the global surgical fee.

Q. How is a reoperation billed if it becomes necessary?

A. Medicare covers procedures within the global surgery period when they require a return to the operating room. Use modifier 78 when a reoperation is billed during the postoperative period. There are several possible reoperations during the postoperative period, including:

► instillation of an air bubble or gas in the anterior chamber (CPT 66020) to reposition the endothelial tissue

► suture through the cornea (CPT 66250) to secure the endothelial tissue

► repeat the DSEK/DSAEK (CPT 65756) to replace the endothelial tissue. OM