Coding & Reimbursement

Medicare Scrutinizes Intravitreal Injections

By Suzanne L. Corcoran, COE

The utilization of intravitreal injections of medications (CPT 67028) in the Medicare program has grown enormously over the past few years. As expected, Medicare is aware of the increase and has begun seriously looking at the medical necessity and documentation of these services. Here's what you need to know.

Q. What diseases are treated with intravitreal injections?

A. Ophthalmologists 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: exudative (wet) AMD, CSME, CRVO, retinal detachment, endophthalmitis, fungal infections, vitreous hemorrhage and CMV retinitis. As may be expected, most injections are given by retina specialists, but more and more anterior segment specialists are finding additional uses for the drugs as well. This only serves to increase the frequency of claims for this code.

Q. How frequently is this service provided?

A. Within the past few years, use of intravitreal injections has dramatically increased due to the introduction of anti-angiogenesis agents for wet AMD. Some ophthalmologists may perform this procedure more frequently; others may elect to avoid this procedure and never report 67028.

Medicare has recently increased its scrutiny of 67028, and there have been a number of large overpayment determinations. Auditors are looking at a number of issues, including:

► Documentation of medical necessity for the injection
► Whether a visit is billable at the time of the injection, and the level of the visit¹
► An operative report, including the dosage administered.

Q. How does reimbursement work?

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 ambulatory surgery center (ASC) rather than the surgeon's office. The Medicare Physician Fee Schedule identifies this as “non-facility” vs. “facility” reimbursement.

In the office setting, injected pharmacologic agents are separately reported on a claim using HCPCS J-codes and reimbursed according to CMS' office-drug payment policy. Note that various Medicare contractors accept different codes for Avastin; check your Medicare policy for the correct code to use in your locality.

In the HOPD and ASC, some drugs, such as Lucentis, are paid separately. They appear, with payable HCPCS codes, in the annual Medicare payment rates for HOPDs and ASCs. Avastin is not on the list, and there is no separate reimbursement for the injected drug in a facility.

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

A. Sometimes. The Medicare global surgery package includes any additional medical or surgical services during the postop 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. Will insurance cover an off label, 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 pre-certification or pre-authorization 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. If a series of injections is planned, you may obtain a single ABN or waiver to cover the planned series, up to a year of services. OM

Reference

1. See this column in the July 2005 issue of Ophthalmology Management for a discussion of modifier 25, or contact Corcoran Consulting Group to order a copy of our FAQ on the topic.

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