Corneal collagen cross-linking (CXL) has been FDA-approved for a while, but questions still arise among eye-care practices. Here are some of the most common we encounter.

Q. What is corneal collagen cross-linking?

A. In keratoconus and corneal ectasia, the corneal stroma has weakened and the cornea thins and bulges out, distorting vision. CXL uses a combination of riboflavin (vitamin B2) and ultraviolet (UVA) light to make collagen in the corneal stroma stronger and more flexible. In most cases, CXL is ideally performed early in the disease process, before vision deteriorates to the point where glasses or contact lenses no longer correct vision.

Q. What is involved in the CXL procedure?

A. The FDA-approved version of CXL involves: removing the corneal epithelium (“epi-off”), placing riboflavin on the corneal stroma for about 30 minutes, measuring corneal thickness (pachymetry) to ensure that the cornea will be thick enough for the physician to proceed and then directing UVA light onto the cornea for about 30 minutes.

While some surgeons don’t remove the epithelium (“epi-on”), The American Academy of Ophthalmology’s Preferred Practice Pattern (PPP) does note that doing so “may decrease the risk of complications associated with epithelial removal, but it may also decrease its efficacy.”¹

Q. What conditions are treated with CXL?

A. CXL is used for the treatment of progressive keratoconus and ectasia following refractive surgery.^2,3 Clinical studies are being performed on the use of CXL for the treatment of corneal infections.^4,5

Q. What is the FDA status of CXL?

A. Currently, there is only one FDA-approved system: Avedro Inc. received approval in April 2016 for Photrexa Viscous, Photrexa and the KXL System. These are photo enhancers indicated for use with the KXL system in CXL for the treatment of progressive keratoconus or corneal ectasia following refractive surgery. The approved protocol requires epithelium removal. The FDA does not currently approve epi-on CXL or CXL for the treatment of corneal infections.

Q. What CPT code identifies CXL?

A. To report this procedure for dates of service on or after Jan. 1, 2016, use Category III CPT code 0402T (Collagen cross-linking of cornea, including removal of the corneal epithelium and intraoperative pachymetry when performed).

Code 0402T may not be reported in combination with CPT codes 65435, 69990 or 76514.

Q. What is the global period for 0402T?

A. There is no defined global period for any Category III CPT code.

Q. Is the riboflavin separately reported on a reimbursement claim?

A. Not in most cases. Unless specifically instructed to do so by a third-party payer, riboflavin (B2) is not separately reported because it is an incidental part of 0402T.

Q. Is CXL covered by health insurance or Medicare?

A. Some third-party payers cover CXL.⁶ Other payers consider CXL experimental and investigational, and do not cover it.⁷ Most payers who cover CXL reimburse epi-off but not epi-on CXL. Predetermination of benefits and prior authorization are advised whenever possible. An Advance Beneficiary Notice of Noncoverage is recommended for Medicare patients. Remember that Medicare Advantage plans are not permitted to use the Medicare ABN form; check with your plans to determine their requirements for predetermination of benefits. OM

REFERENCES

1. American Academy of Ophthalmology. Preferred Practice Pattern. Corneal Ectasia. 2013. https://www.aao.org/preferred-practice-pattern/corneal-ectasia-ppp--2013 . Accessed Sept. 28, 2017.
2. Galvis V, Tello A, Ortiz A, Escaf LC. Patient selection for corneal collagen cross-linking: an updated review. Clin Ophthalmol. 2017;11:657-668.
3. American Academy of Ophthalmology. EyeWiki. Corneal Collagen Cross-Linking. http://tinyurl.com/cvo2b8d . Accessed Oct. 20, 2017.
4. Makdoumi K, Mortensen J, Crafoord S. Infectious keratitis treated with corneal cross-linking. Cornea. 2010 Dec;29:1353-1358.
5. Sorkhabi R, Sedgipoor M, Mahdavifard A. Collagen cross-linking for resistant corneal ulcer. Intl Ophthalmol. 2013; Feb;33:61-6.
6. Aetna. Corneal Remodeling. Last Review 03/29/2016. http://tinyurl.com/8yhxjqj . Accessed Sept. 28, 2017.
7. BlueCross BlueShield of North Carolina. Corneal Collagen Cross-Linking. Last review 06/2015. http://tinyurl.com/y78quc5n . Accessed Sept. 28, 2017.

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