Amniotic membrane tissue (AMT) has important uses throughout medicine, including ophthalmology. Here’s what you need to know to code properly for those uses.
Q. What is amniotic membrane tissue, and how is it used?
A. AMT is the inner layer of the placenta that surrounds the fetus during pregnancy. AMT for medical use is obtained from donors following pregnancy. It is available in various forms and sizes for different uses; it is supplied as dehydrated tissue that is reconstituted as needed, and also cryopreserved tissue.
AMT in eye care is used as a biological bandage or surgical graft. As a biological bandage, it is used primarily to treat acute and chronic corneal surface wounds and defects. In this form, AMT shields the regenerating epithelium from frictional forces during the healing process and protects the underlying stroma if it is inflamed or scarred. Some common ophthalmic conditions for which AMT could be used include:
- Chemical burns of the ocular surface
- Corneal epithelial defects such as:
- Bullous or band keratopathy
- Epithelial basement membrane dystrophy
- Recurrent corneal erosions
- Keratitis (exposure, neurotrophic, filamentary, bacterial or viral)
- Postop care after corneal procedures
- Postop care after pterygium surgery
- Corneal ulcer
- Partial limbal stem-cell deficiency
- Persistent epithelial defects (delayed healing)
- Stevens-Johnson syndrome
AMT can also be used as a graft to facilitate ocular tissue repair or as a biological dressing to protect the ocular surface. As a graft, it provides a natural substrate that is conducive for migration and attachment of the patient’s own epithelial cells.
Some common indications for AMT as a surgical graft include:
- Pterygium and pinguecula surgery
- Conjunctivochalasis and conjunctival lesion surgery
- Superior limbic keratoconjunctivitis
- Leaking bleb repair
- Descemetocele or perforation
- Fornix and socket reconstruction
Q. What CPT codes describe placement of AMT?
A. There are several depending on how the AMT is used:
65778 – Placement of amniotic membrane on the ocular surface; without sutures
65779 – Placement of amniotic membrane on the ocular surface; single layer, sutured
65780 – Ocular surface reconstruction; amniotic membrane transplantation; multiple layers
In addition, instructions in CPT include: For placement of amniotic membrane using tissue glue, use 66999.
Q. Why does the use of tissue glue affect reimbursement?
A. The FDA has not cleared tissue glue for use with amniotic membrane. The use of tissue glue in these cases is off-label and could be considered experimental or investigational. From a coding perspective, use of tissue glue with AMT is reported with a miscellaneous code, 66999. This code has no preset RVUs and no specific postoperative period. It has no reimbursement in an ASC and only minimal reimbursement in an HOPD; it is also subject to lengthy claims processing periods.
Q. What does Medicare allow for these procedures?
A. Physician payment rates vary depending on the site of service. There is a large site-of-service differential between physician reimbursement in-office and in-facility due to the supply. Payment for the supply of AMT is not made to the physician when the procedure is performed in a facility.
The 2017 Medicare allowable amounts are below. These amounts are adjusted in each locality by local indices. Other payers set their own fee schedules, which may differ considerably from Medicare rates.
| 65778 | 65779 | 65780 | |
|---|---|---|---|
| Physician in office | $1,440 | $1,219 | $678 |
| Physician in facility | $59 | $155 | $678 |
| HOPD facility fee | - | $2,774 | $2,774 |
| ASC facility fee | - | - | $1,303 |
Q. Does Medicare pay separately for the supply of AMT?
A. No. HCPCS code V2790, Amniotic membrane for surgical reconstruction per procedure, is no longer eligible for discrete Medicare payment in any setting. Reimbursement for the supply is included with payment for the procedure.
Other payers might have different policies regarding AMT, so check with them.
Q. Are there any restrictions on Medicare reimbursement?
A. Yes. Medicare’s National Correct Coding Initiative (NCCI) edits bundle AMT transplantation procedures with pterygium removal (65420, 65426) and with the keratoplasty codes (65710, 65730, 65750, 65755, 65756). Use of a bandage contact lens (92071) is bundled with 65778. NCCI edits change quarterly, so check them periodically.
Other third-party payers are not obliged to follow Medicare’s NCCI edits, although many do. Check with the payers. OM
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