CODING Q&A
Avastin Reimbursement: Sorting Out the Confusion
ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. I have had so many conflicting instructions on how I can bill for intravitreal injections of ranibizumab (Avastin). Could you provide some clarifications?

A. For Medicare, this is still a work in progress and the final determination is made by your local Medicare carrier. Not all carriers have yet to tackle this. It is imperative that you get written directions from your carrier's medical director or someone in authority at the policy level. This communication may be via a special bulletin, in the news alert, or by personal written communication. The answer varies from 1 Medicare carrier to the other.

However, most carriers are currently putting out notices that both the procedure (CPT code 67028) and the supply (usually J3490 because the systemic Avastin supply is not the correct dosage and is not what is actually used) are not covered services based on the premise that the drug is considered investigational; therefore, the method for delivery of that drug also must be considered investigational, and thus not a benefit under the Medicare program.

I strongly urge you to read the policies on either Off-Label Use of Drugs for Nononcologic Conditions (www.kansasmedicare.com) or Off-Label Coverage of FDA Approved Drugs (www.empiremedicare.com). Understanding this concept will help you in future management of use of off-label drugs and reimbursement issues.

Misunderstandings initially occured when some practices billed for the procedure and the carriers did not realize the claim was for an investigational drug and proceeded to pay it. Now, the carriers are beginning to issue instructions to providers that these monies need to be voluntarily refunded.

At the same time, some carriers are issuing specific directions that they are to be billed after the monies are collected from the patient, and to append a GA modifier to the service. A good rule to follow with intravitreal Avastin injections is that, with all carriers, the patient must pay up front for the procedure and supply. Any reimbursement that is allowed under the specific carrier's policies will then come later.

Be careful. If your carrier has not geared up to have these claims rejected, you will be paid and will be in the uncomfortable position of having to refund monies paid. Make sure you have instructions from your carrier to do this. Different states under the same carrier may have different instructions.

Lastly, do not forget to have a proper informed consent signed. One specifically for intravitreal injection of Avastin may be downloaded from the OMIC website (www.omic.com).

Q. Could you please explain why I cannot perform intravitreal injections in an ambulatory surgery center (ASC)? It is much easier for me to perform the injection there and have the ASC deal with purchasing the drug and getting reimbursed for it?

A. CPT procedure code 67028 (Intravitreal injection of pharmacologic agent) is not on the list of procedures covered by Medicare in an ASC. Thus, it becomes a noncovered service and the physician has to pay for it, not the patient. A facility is prohibited from billing a patient for a procedure that is a covered procedure for Medicare under ordinary circumstances, when it is performed in an ASC. Therefore, the physician has to pay for the service and the supplies because failure to do so may be construed as an inducement. This rule applies whether or not the physician is an owner/part owner or is just using the facility.

Q. There was a conversation on a practice management list serve dealing with the necessity of vitals (pulse, blood pressure, respiratory function) prior to the performance of any procedure in any location. I did not see any final word on this. Does anyone know if we do indeed need to measure this for a focal laser or Macugen injection performed in the office?

A. The requirement for vital sign measurements does not apply to procedures performed in the office setting. This is frequently confusing to billing people who are given this information at seminars and do not realize that such requirements pertain only to given sites of service.

CPT codes copyright 2005 American Medical Association.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com.