LETTERS

Intravitreal Injections: A Minor Procedure?

I enjoy reading the coding segment of your magazine, especially the article in the September 2013 issue “Modifier 25 + Intravitreal Injections + NCCI Bundles.” However, I have one burning question: Why is the examination of an eye and then an intravitreal injection into the vitreous cavity considered a “minor procedure” and so a bundleable service”?

I understand that, by definition, a procedure considered to be “minor” bundles the examination and the procedure into one payment. I also certainly agree that the exam and decision to remove an eyelash rubbing against the cornea or lancing a hordeolum falls into this category of a very limited exam, combined with a simple minor procedure.

However, I don’t understand how this categorization can be logically applied to intravitreal injections of VEGF-inhibitor drugs. Riva Lee Asbell notes, “specious arguments and rationalizations will not change this.” However, I don’t think the argument is “specious,” or erroneous, fallacious, or unsound.

WHAT WE’RE PAID

We are currently paid $107.42 for each intravitreal injection. The surgeon’s clinical decision-making to administer an injection into the vitreous cavity of the eye includes the risk of potentially causing a blinding infection.

The physician does not undertake lightly the decision to inject a very expensive drug, which also carries the risk of stroke or death to the patient, into the eye. The pre-injection examination requires a moderate problem-focused preoperative interval history and examination to determine that the patient has not had an interval myocardial infarction, TIA, stroke, or uncontrolled blood pressure since the last visit.

The pre-injection evaluation also requires determination of the patient’s BCVA, an assessment of the quality of vision, a careful examination of the anterior segment to rule out inflammation, a detailed examination of the macula to search for blood, fluid, and lipid, and a peripheral exam to rule out interval retinal tears.

Ms. Asbell notes that Medicare’s global fee for minor procedures is 10% for preoperative care. We are therefore compensated $10.74 for this effort.

WHAT IT REQUIRES

Preinjection testing sometimes requires a fluorescein angiogram, but at the very least, color photos are necessary to document blood or lipid and its extent for comparison to past and future visits. It also requires SD-OCT to search for signs of activity, which is always compared with the last and sometimes several prior visits.

Medicare considers fundus photos and OCT images duplicative, so CMS will only pay for the less expensive OCT. As a result, although we perform this “minor” procedure, Medicare does not compensate us for all of the indicated testing. This is not factored into the global fee concept.

Once the ophthalmologist collects and analyzes all this information, he or she makes a customized determination for that specific patient visit, to decide whether to inject a $2,000 drug through the pars plana.

A PAINSTAKING PROCEDURE

Sufficient time must be set aside to sterilize the operative field adequately and to draw up the proper dose of medication using sterile techniques. The “simple” injection, which hopefully avoids striking the crystalline lens or not injecting through the retina, has a 2-mm margin of error.

If the surgeon strikes the lens, cataract surgery is necessary, and if the retina is punctured, a retinal detachment will follow. Then, following the injection, more time is necessary to re-examine the retina and ensure that the injection did not cause a retinal tear or hemorrhage, to check that vitreous tissue was not incarcerated into the injection site, and to determine that the central retinal artery is patent.

This procedure also mandates monitoring the patient until the IOP equilibrates to allow for the return of at least LP vision. Then, a discussion follows, with a take-home instruction sheet regarding postoperative care and specific issues that the patient should directly and promptly report to the surgeon. What part of this argument is specious?

THE JEWELER’S METAPHOR

I fear the answer to my question is that Medicare, National Correct Coding Initiative, or the Relative Value Update Committee decided an intravitreal injection is a minor procedure, probably citing that it only takes a few moments to inject the drug.

Just as it only takes a few moments to cut the Hope Diamond, it only takes a few moments to inject the drug. If done improperly, it takes hours to fix and may, as improperly cutting a precious stone, result in “dust” (blindness).

The judgment and experience to know when and how to give an intravitreal injection takes years to acquire and mandates continuous education to keep up with the results of the most recent clinical trials and new drugs, with the ultimate goal of providing high-quality, cost-effective care. Again, what part of this argument is specious?

NEGATIVE TREND

We have quietly accepted yearly ratcheting down of the compensation for intravitreal injections, from $500 to $107.42. Meanwhile, the Centers for Medicare and Medicaid Services (CMS)readily grants drug companies payments of thousands of dollars for their new products, which require risk, time, and expertise to administer.

We have accepted that it is not ethical or legal to “split” a vial of Lucentis between two patients, although this is common practice in other developed countries, and it has no effect on the total cost to Medicare.

Medicare spends the same overall dollar amount if we use one vial per patient and discard the rest or split the vial between two patients. The only difference is that the doctor would financially benefit instead of the drug company.

We were silent when OCT payments first decreased and then were bundled for two eyes. We have tolerated the determination that a color photograph and an OCT are “duplicative” tests (which is not true) and therefore mutually exclusive. And we have accepted compensation for the less expensive of the two procedures.

We have even been silent when we inject each eye on the same day and are paid half for the second eye (which saves the patient’s family the expense and time off from work for another trip to the doctor’s office). Not compensating us fairly for the examination, separately from the injection, will have devastating financial consequences for many practices.

A CALL TO ACTION

It is time that the American Society of Retina Specialists, Retina and Macula societies, and American Academy of Ophthalmology convince the powers that be that intravitreal injections are not minor procedures. Or the global fee should be significantly increased to reflect the work performed.

CMS should fairly compensate us for our time and expertise and for the enormous overhead expenses to provide the latest technology, so we can continue to offer the best care to our patients. RP

Paul E. Tornambe, MD, FACS

San Diego, CA