Coding & Reimbursement

Laser-assisted keratoplasty: Know the coding details

By Suzanne L. Corcoran

Keratoplasty, another name for corneal transplant, is commonly performed using a trephine, but it could also be performed with a femtosecond (FS) laser. There are some clinical advantages to using the latter, but be sure to check for coverage first.

Q. What is femtosecond laser-assisted keratoplasty?

A. FS laser-assisted keratoplasty is a form of keratoplasty that uses a FS laser to create incisions for certain types of corneal transplantation. The FS laser can be used on the donor tissue, recipient or both. The FS laser enables the surgeon to create complex shaped incisions, such as “top hat” or “zigzag”, so the recipient and transplant tissue may be precisely fitted together like an intricate puzzle. The result is a potentially stronger graft.¹

In contrast, traditional penetrating keratoplasty (PK) uses a handheld, bladed “cookie cutter” called a trephine to make a full- or partial-thickness, vertical and circular, incision. There are often difficulties in having the corneal walls remain perfectly vertical. Using a separate trephine, the surgeon prepares a plug-shaped tissue graft from a donor. With trephine preparation, the transplanted tissue graft is placed into the space; it requires suturing to maintain its position. The sutures stay in the eye for a year or longer. Patients generally do not achieve full visual recovery until a prolonged period of time has passed, due to slow healing and subsequent changes in corneal curvature and astigmatism.

Q. What are the indications for FS laser use with keratoplasty?

A. Indications for using the FS laser with these corneal procedures are the same as those for any anterior lamellar or PK procedure — the only differnce is the use of the laser. They include: pseudophakic bullous keratopathy, corneal scars, corneal degenerations and dystrophies, keratoconus and corneal graft issues requiring repeat surgery.

Q. What CPT codes best describe FS laser-assisted keratoplasty?

A. Keratoplasty is the general term for corneal transplant. CPT code 65710 refers to anterior lamellar corneal transplant (shallow or deep, but not full thickness). CPT codes 65730, 65750 and 65755 refer respectively to full thickness (penetrating) corneal transplantation in a phakic patient, aphakic patients (those with no native or artificial lens), and pseudophakic patients (those with an IOL already in place). Select the CPT code that matches the corneal procedure and the patient’s lens condition.

On Jan. 1, 2012, two new add-on Category III CPT codes were added to describe use of the FS laser with the above codes. They are:

+0289T Corneal incisions in the donor cornea created by using a laser, in preparation for penetrating or lamellar keratoplasty. (List separately in addition to code for primary procedure.)

+0290T Corneal incisions in the recipient cornea created by using a laser, in preparation for penetrating or lamellar keratoplasty. (List separately in addition to code for primary procedure.)

Q. What is the significance of these Category III codes?

A. Category III codes are described as “temporary codes for emerging technology, services, and procedures …”. Payers mainly use them for data collection about new services.

Most local coverage determinations (LCDs) specifically note restrictions on coverage for Category III codes. If a policy labels a procedure or device as “experimental or investigational” or “not reasonable and necessary”, coverage is unlikely. Other payers’ policies could differ significantly from CMS’.

The Medicare Physician Fee Schedule does not include payment rates for Category III codes for the surgeon; they are priced locally. There is no separate facility payment to a hospital or ASC for these codes, since they are physician services only.

Q. May we collect a separate fee if the patient signs a financial waiver?

A. In the absence of a specific policy, yes. Explain to the patient why you think this is the best option, but that Medicare or other third-party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

• An Advance Beneficiary Notice (ABN) of Noncoverage is required for services in which Part B Medicare coverage is ambiguous or doubtful, and might be useful if a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.

• For Part C Medicare (Medicare Advantage [MA]), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA plans might have their own waiver forms.

• For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits is an alternative to an ABN.

Q. How should we document the use of the FS laser in the medical record?

A. The operative report should reflect the use of the FS laser on the host and/or donor tissues during or before the anterior lamellar or traditional keratoplasty. A description of the use of the FS laser should include: diameter, depth and shape of the incisions; issues such as difficulties or problems encountered during use; and all complications. OM

REFERENCE

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