Coding & Reimbursement

Testing & Billing for Ophthalmic Side Effects

By Suzanne L. Corcoran, COE

Plaquenil, and other anti-malarial drugs, may seem to be an odd topic for a column on ophthalmic coding. However, they have found use in treating systemic disease and can have adverse ophthalmic effects. Since these may well show up in your patients, here are the essentials on diagnosis and billing.

Q. What is Plaquenil?

A. Plaquenil (hydroxychloroquine sulfate) is used by physicians to treat rheumatoid arthritis and lupus erythematosus when other drugs have failed, although its exact mechanism of action is unknown in both conditions. Plaquenil is also gaining credence as treatment for antiphospholipid antibody syndrome (APS). It was originally used mainly for treatment of malaria, but that disease is not common in the United States.

Q. Why do ophthalmologists see patients who are on Plaquenil therapy?

A. The drug has a number of possible side effects. In eye care, we examine patients taking Plaquenil because the drug can cause retinal toxicity and permanent visual field and visual acuity loss. Early detection has been the goal for eyecare providers, since some patients may experience continued functional loss and depigmentation even after stopping use.

Q. Do Medicare and other payers cover exams and tests for Plaquenil use?

A. Usually. The first baseline exam takes place a few months after starting Plaquenil, so the treating physician and patient can be reasonably certain the medication will be tolerated. Other exams are usually annual. Most payers cover annual exams associated with long-term systemic drug use.

Q. What tests are usually done?

A. Yearly exams with Amsler grid, color vision testing and central threshold perimetry have been the standards for detection of ophthalmologic changes, with visual field testing being considered the “gold standard” for earliest detection.

Amsler grid and color vision testing are incidental tests in this context, and are not separately billable. The visual field standard has been the Zeiss-Humphrey 10-2 macular test or its equivalent (92083).

Q. I recently read that OCT testing is now indicated for Plaquenil patients. Will payers cover this testing?

A. In February 2011, the American Academy of Ophthalmology issued a new set of guidelines for screening these patients. OCT technology was endorsed as one method of early detection, and some Medicare contractors and private payers have begun to issue specific advice based on these recommendations.

WPS, the Medicare contractor for Wisconsin, issued LCD #L29971, effective June 1, 2011, that endorses OCT testing using CPT 92134, but with specific guidance as to the type of OCT used. It states:

“Clinical evidence shows that the resolution of time-domain OCT instruments is not sufficient … Because of that, spectral domain optical coherence tomography is expected to be used to detect retinal changes … Eyecare providers without SD-OCT equipment should refer beneficiaries to offices or centers that have SD-OCT available.”

WPS further specifies that to properly bill for 92134 in this case: “… place “SD-OCT” in box #19 to reflect that this form of Optical Coherence Tomography was used.”

Q. What diagnoses should I use for the exam and testing?

A. There are very few ICD-9 codes that pertain. Most payers want the diagnosis for the systemic disease first (e.g., 714.x for rheumatoid arthritis), followed by the V-code for use of high-risk medications. Some payers also want the E-code (E931.4) to identify the drug.

• V58.69–Long-term (current) use of other high-risk medications
• V67.51–Following completed treatment with high-risk medications, patient is still being followed for use of the medication

If a patient develops macular changes due to Plaquenil use, ICD-9 specifies that the drug must also be coded as the external cause. The claim will include both codes.

• 362.55–Toxic maculopathy
• E931.4–Hydrochlorquine sulfate (antimalarial drugs)

Remember that using these diagnosis codes when the true purpose of the exam and testing is to monitor for problems associated with drug use is inappropriate until there are actual macular changes noted.

Q. If Plaquenil is planned but not yet started, is the exam covered?

A. Examinations and tests before starting medication are likely to be classified as screening and not covered, unless there is another reason for the eye exam. Some payers have different policies, so you should check. For example, Wisconsin's LCD #L29971 states, in part, that some testing “may be indicated to provide a baseline prior to starting the medication.” OM

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