CODING Q&A

Medicare Rulings on Intravitreal Injections (Part I)

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. When doing intravitreal injections, such as Lucentis and Avastin, do you just use numbing drops prior or can you actually perform and charge for a subconjunctival injection?

A. When a procedure is being performed, Medicare does not pay the surgeon for anesthesia, except for certain circumstances as described below.

The Medicare Learning Network article MM 5618 issued in conjunction with the transmittal R1324 CP issued August 27, 2007, states:

“The continuum of complexity in anesthesia services (from least intense to most intense) ranges from (1) local or topical anesthesia, (2) moderate (conscious) sedation, (3) regional anesthesia, to (4) general anesthesia. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. It does not include minimal sedation, deep sedation or monitored anesthesia care.”

Currently, section 50A instructs carriers and MACs not to allow separate payment for the anesthesia service performed by the same physician who furnishes the medical or surgical services. For example, there is no separate payment allowed for a surgeon's performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure. The revised policy is: If the physician performing the procedure also provides moderate sedation for the procedure, then payment may be made for conscious sedation consistent with CPT guidelines; however, if the physician performing the procedure provides local or minimal sedation for the procedure, then no separate payment is made for the local or minimal sedation service.”

The subconjunctival injection that you describe should not be billed.

Q. Does anyone have or know of a Medicare policy on Triesence? I am trying to determine for which diagnosis codes it is covered?

A. There is no national policy on Triescence. A national policy is one issued by CMS and that applies to all contractors. It is referred to as a National Coverage Determination. There are very few in ophthalmology.

A policy that includes covered diagnoses for using Triesence for intravitreal injections may be issued by an individual Medicare contractor. When a drug is used off-label, certain guidelines apply.

A similar problem surfaced some years ago when Avastin was initially used off-label for treating wet AMD. There was a lot of misinformation coming from all sources at that time that eventually resulted in refunds to the carrier(s). The practices could not recover from the patient since no Advance Beneficiary Notice (ABN) had been signed.

Whenever a drug is being used off-label and its use is not specifically covered by the carrier/contractor, it is not covered under the Medicare program. Individual contractors have their own LCDs (Local Coverage Determination) for off-label use of drugs. If the drug is not covered, then neither is the method of delivery. Thus, the intravitreal injection is not covered either. The patient must pay for both. An ABN should be signed prior to the procedure in order to avoid later complications.

Q. We are having an issue with Carrier X paying for the injection (code 67028) but not for the drug for patients treated with Avastin for conditions other than 362.52 (wet macular degeneration). We did receive the notice from the Medical Director that, effective April 1, they are now paying for four other diagnosis codes.

A. This is a similar situation that occurred early on as described in the above example. Since the use was off-label, the contractor should not have been billed for the injection.

Please remember that, when dealing with Medicare, being paid means simply that — you were paid. Medicare generally pays claims and comes back later with a friendly letter requesting a refund when they recognize the problem. RP

CPT codes copyright 2006, American Medical Association.