Coding & Reimbursement

Coding for Intravitreal Injections

By Suzanne L. Corcoran, COE

Ophthalmologists, generally retina specialists, currently utilize intravitreal injections to treat a number of retinal conditions. Many of the diseases are severe, with poor prognoses and limited treatment options. They include: wet AMD, clinically significant macular edema, central retinal vein occlusion, retinal detachment, endophthalmitis, fungal infections, vitreous hemorrhage, and cytomegalovirus retinitis. Here is some information about coding for these injections that may be helpful to you.

Q. What considerations affect coding and reimbursement of intravitreal injections?

A. There are several, including: medical indication (e.g., FDA approved, off-label, investigational, experimental), substance injected (pharmaceutical or vitreous substitute), concurrent surgical procedure (if any), history of prior surgical procedure (if any), postoperative care and location where intravitreal injection was given (office, ASC, or hospital outpatient department).

There are two CPT codes that describe intravitreal injections. They are distinguished by the injected substance:

• 67025 Injection of vitreous substitute, pars plana or limbal approach, fluid-gas exchange, with or without aspiration, separate proce dure.
• 67028 Intravitreal injection of a pharmacologic agent, separate procedure.

Code 67025 is a major surgery with a 90-day postoperative period while 67028 is a minor procedure with zero postoperative days.

Q. Will insurance cover an offlabel, investigational or experimental use of medication delivered by intravitreal injection?

A. Maybe, but don't plan on it. Insurance coverage is variable and oftentimes unpredictable. For the sake of prudence, obtain precertification or preauthorization from the third-party payer.

Alternately, ask the patient to assume financial responsibility in the event that reimbursement is denied. Use an Advance Beneficiary Notice of Noncoverage (ABN) for Medicare patients, or a financial waiver for non- Medicare patients, to document the patient's acceptance.

Q. Is this procedure reimbursed during the postoperative period of another surgery?

A. Sometimes; Medicare global surgery package includes any additional medical or surgical services during the postoperative period to treat a complication that does not require a return to the operating room (MCPM Ch.12, §40.1A). So, unplanned injections performed in-office to cope with complications are not separately reimbursed.

However, if the injection is given in an OR, then it may be reimbursed (requires modifier 78). Lastly, preplanned intravitreal injections are not part of the global surgery package and are covered under the rules for staged procedures (requires modifier 58). Other payers may have different coverage guidelines.

Q. What if the intravitreal injection is given in an ASC?

A. Under Medicare's site of service rules, reimbursement for the surgeon's professional fee is lower when the injection is given in a hospital outpatient department (HOPD) or ASC rather than the surgeon's office. The Medicare Physician Fee Schedule identifies this as "non-facility" vs "facility" reimbursement.

CMS inaugurated a new payment system for ASCs on Jan. 1, 2008, which mirrors the Ambulatory Payment Classification system for HOPDs. The system is now in its second year of transition. The 2009 facility payment for 67025 is $612.94 and $84.76 for 67028. Prior to 2008, 67028 was ineligible for reimbursement in an ASC.

Q. How is the injected substance reimbursed?

A. In the office setting, injected pharmacologic agents are separately reported on a claim using HCPCS codes and reimbursed according to CMS's office-drug payment policy. The amount of reimbursement is equal to the average selling price of the drug plus 6%. In the HOPD and ASC, reimbursement for vitreous substitute (e.g., SF6, C3F8, perfluorocarbon, hyaluronidase) is usually included in the facility fee. However, some other drugs, such as Lucentis, are paid separately. They appear, with payable HCPCS codes, in the annual Medicare payment rates for HOPDs and ASCs.

Effective Oct. 5, 2009, and retroactive for services to Jan. 1, 2009, there is a new HCPCS code for intravitreal Avastin: Q2024 (Injection, Bevacizumab, 0.25 MG). J-codes are no longer used for this service. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.