CODING Q&A

Clearing Up Medicare Questions on Intravitreal Injection Reimbursement

INFORMATION PROVIDED BY RIVA LEE ASBELL

The listservs are full of repetitive questions concerning intravitreal injections — demonstrating the lack of comprehensive understanding on the subject and the difficulty of getting proper advice. This month, we will review some of the more burning questions I am receiving and that are presenting on the listservs. All answers pertain to Medicare only.

Q. For Medicare, how would you code bilateral Avastin injections? Specifically, what modifiers would you use for 67028?

Q. Does anyone know for Medicare how to code intravitreal injections performed for both eyes in the same session? Do you use 67028-50 and double the amount charged? Do you get paid full amounts for each eye?

A. CPT code 67028 (Intravitreal injection of a pharmacological agent) is the surgical procedure code. Whenever multiple surgical procedures are performed during the same session, Medicare's multiple surgery payment guidelines apply. This states that you are to be paid 100% of the allowable for the initial procedure (the highest paying procedure) and 50% of the allowable for the next four procedures. If there are more than four pro cedures, the claim is individually considered.

In this case, two procedures were performed on the same day and thus are subject to multiple surgery pricing. You will be paid 100% of the allowable for the first injection and 50% of the allowable for the second injection in the fellow eye. So you get 150% of the allowable, not 200%. Charge your standard fee for each eye.

Your coding should look like this:
67028 – RT
67028 –51-LT

Note: some contractors' carriers do not require the 51 modifier. If you prefer to use the 50 modifier and your contractor accepts this, remember not to use the 50 modifier in ASC billings — you will not be paid for a bilateral service.

Q. How do you code for Medicare PDT (listed as OPT – Ophthalmic Photodynamic Therapy) and intravitreal injections performed in the same session: 67221 and then 67028-51? Do you get paid in full for 67221 and 50% for 67028? Is modifier 51 needed?

A. This reader understood the concept of multiple surgery payment correctly (just lacking a little confidence). Modifier 51 is the one used to indicate each subsequent procedure and you must check with your Medicare contractor/carrier to see whether they want you to use it or not. It varies from contractor to contractor

Q. We have a retina specialist who rents space from us a few times a month specifically for patients requiring Lucentis injections. When he is here the office is a madhouse and both our reception and dilating areas are overflowing. My managing partner asked me today if Lucentis injections can be administered in the ASC setting. He felt it might help our crowding situation to have the patients seen there. I am pretty sure that this service is not one approved for the ASC setting, but I thought I would ask just to be certain. Thank you for any assistance.

A. With the advent of ASC payment reform in 2008, intravitreal injections are paid for when performed in an ASC. The decision regarding where to perform the injection is complex one, dependent on many factors. It warrants sophisticated financial analysis. Factors to take into consideration include the practice's physician payment calculations, ownership of the ASC, whether volume is sufficient to warrant the ASC administrative costs, and the best utilization of available slots.

When the injection is done in the office, average national 2010 reimbursement based on projected conversion factor 36.0666 is $189.71 under CPT code 67028.

When the injection is done in an ASC, the average national 2010 reimbursement based on the same projected conversion factor is $162.66 for the physician fee under code 67028 and $71.58 as the ASC payment. RP

CPT codes ©2010 American Medical Association.