Coding & Reimbursement

When floaters require treatment

How to bill for them without a misstep.

By Suzanne L. Corcoran

Vitreous floaters can be annoying, but most do not require treatment.

Let’s discuss what you need to know to obtain reimbursement when treatment is necessary.

Q. What is the medical rationale for treating vitreous floaters?

A. When a floater is significant, limiting vision and compromising the patient’s ability to function, surgical treatment could have merit. That is the exception, not the rule. One published article indicates most floaters require no treatment other than patient reassurance.¹

Q. What factors argue in favor of lasering vitreous floaters?

A. Treating vitreous floaters with laser may be considered in cases in which:

• There is a severe handicap

• Activities of daily living are seriously hindered

• Symptoms do not resolve over time

• The benefit of treatment outweighs the risk.

As with any other surgical procedure, informed consent is critical. It encompasses the risks (such as retinal detachment), benefits and alternatives to treatment.

Q. Is laser treatment of vitreous floaters successful?

A. Maybe. A 2002 article described moderate improvements in fewer than 40% of those treated with YAG laser.² Earlier articles described higher success rates.^3,4 A published book on the subject references a formal study completed in March 2005.⁵

Q. Is this procedure reimbursed by third-party payers?

A. There are few coverage policies on this topic. One, by Aetna, considers this treatment “experimental and investigational … because its effectiveness for these indications has not been established” and therefore not covered.⁶

Florida Blue Cross/Blue Shield says, “Laser vitreolysis is considered experimental or investigational … specifically vitreous floaters of the eye…”.⁷

Q. Do any CPT codes describe lasering vitreous floaters?

A. There are two CPT codes that apply: 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages) and 67299 (Unlisted procedure, posterior segment).

Use CPT 67031 to describe a visually significant opaque floater that is severed from its attachment, allowing it to sink to the bottom of the vitreous and out of the line of sight.

When severing does not occur, CPT 67031 does not apply, so CPT 67299 is the only valid choice.

Q. What are Medicare payment rates for 67031?

A. Medicare offers three rates:

• The national Medicare Physician Fee Schedule amount in 2015 for CPT 67031 is $392 if the procedure is performed in the office, and $360 when performed in a hospital outpatient department (HOPD) or ambulatory surgery centers (ASC).

• The national HOPD reimbursement in 2015 is $443.

• For ASCs, the Medicare-permitted amount in 2015 is $243.

These amounts are adjusted by local indices, so actual payments will vary. In all cases, other third-party payers set their own rates, which may differ considerably from Medicare’s.

Q. What should be known about using 67299?

A. The use of unlisted codes poses administrative challenges.

• No stipulated reimbursement schedule exists for physicians: Payments are decided on a case-by-case basis.

• There is no published global period.

• HOPD reimbursements are the same as for a YAG capsulotomy ($428).

• Within Medicare, unlisted codes are ineligible for ASC facility fee reimbursement.

• Each claim stands alone; reimbursement for one case does not set precedent for the next.

Q. How frequently is laser vitreolysis performed?

A. Rarely. Within the Medicare program, CPT 67031 was reimbursed 3,023 times in 2013. The unlisted CPT code, 67299, was paid only 257 times in 2013 (and not only for vitreolysis).

Ophthalmologists who frequently perform this procedure may attract unwanted attention as outliers. When a surgeon is challenged during postpayment review of a rarely performed procedure, lucid chart documentation is your best defense.

Q. If reimbursement is unavailable or uncertain, what is the next step?

A. First, ask for prior authorization, if possible, from third-party payers.

If prior authorization is not possible, as in the Medicare program, use a financial waiver form, such as an Advance Beneficiary Notice. OM

REFERENCES

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