Coding & Reimbursement

How to code for reshaping the cornea

Intrastromal corneal ring segments are covered — sometimes.

By Suzanne L. Corcoran

Corneal-thinning disorders often lead to protrusion, irregular astigmatism and even perforation. They include conditions such as keratoconus, pellucid marginal degeneration (PMD) and keratoglobus; corneal ectasia can also develop following LASIK. Corneal ectatic disease may impair vision. Though it can often be restored by optical means such as glasses or contact lenses, severe cases may require surgical correction; one option is the use of intrastromal corneal ring segments (ICRS).

Q. What are ICRS?

A. ICRS are designed to reshape the curvature of the cornea; the FDA has approved the device for reduction of mild myopia and stabilization of keratoconus. They are crescent-shaped inserts made from polycast polymethylmethacrylate that are surgically implanted into the periphery of the cornea by an ophthalmologist during a brief outpatient or office procedure. They are available in various sizes based on the condition being treated and the patient’s prescription.

Q. Why use ICRS to treat keratoconus?

A. Historically, penetrating keratoplasty (PK) has been the surgical treatment of choice for keratoconus; treatment with ICRS is both reversible and less invasive. Recovery time is faster and the cost is significantly lower than transplant procedures. Patients may even wear contact lenses again if required. ICRS does not preclude PK at a later time should that become necessary. Long-term results with ICRS have been positive; they show topographic and refractive stability as well as an increased tolerance for contact lens wear.¹

Besides the surgeon’s office, implantation of ICRS may be performed in an ambulatory surgery center (ASC) or hospital outpatient department (HOPD).

Q. Will third-party payers reimburse the surgeon for implantation of ICRS?

A. Sometimes; it depends on the reason for the procedure. Cosmetic refractive surgery (e.g., correction of myopia) is not covered by most third-party payers. Alternately, implantation of ICRS for keratoconus or other corneal ectatic disorders is a medical procedure with a therapeutic intent that will probably be covered.

Because coverage policies vary, we recommend obtaining prior authorization from the third-party payer. Some payers may allow coverage of ICRS for post-LASIK or post-PRK ectasia or other conditions, while others restrict it to keratoconus.

Q. What CPT code is used to describe this procedure?

A. As of Jan. 1, 2016, CPT code 65785 (Implantation of intrastromal corneal ring segments) replaces Category III code 0099T.

Q. What is the reimbursement for 65785?

A. The 2016 national Medicare Physician Fee Schedule allowable for 65785 is $2,148 if performed in-office, and $396 if performed in a facility. These amounts are adjusted in each area by local wage indices. Other payers set their own rates, which may differ significantly from the Medicare published fee schedule.

For ASCs and HOPDs, a new APC code, 5492, was created for this procedure. The 2016 national Medicare rate for ASCs is $1,794, and the rate for a HOPD is $3,381.

Q. Is there separate reimbursement for the supply of ICRS?

A. No. The device is an inherent part of the surgical procedure, 65785. Payment for the device is included in the surgeon’s professional fee when the procedure is performed in the office, or in the facility fee for the ASC or HOPD.

Q. May we charge separately for use of a femtosecond laser to make the corneal channel for ICRS?

A. No. A surgeon chooses the desired surgical instrumentation to perform a procedure. Although additional cost is associated with using a femtosecond laser, the procedure is covered by the beneficiary’s health plan and a separate charge cannot be made for the laser. When the surgeon and the facility accept assignment of benefits, this agreement precludes balance billing the beneficiary for any part of a covered service. This concept is also expressed in the CMS guidance regarding laser-assisted cataract surgery. OM

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