CODING CORNER

Five Keys to Successfully Coding Anti-VEGF Medications and Avoiding Audits

BY JOY WOODKE, COE, OCS

Intravitreal injections have become the most frequently billed procedure in ophthalmology. Receiving the appropriate reimbursement for the medication is crucial. With an increase in audits surrounding intravitreal injections, defense is necessary. Partnering correct coding and appropriate documentation can help provide positive outcomes.

1 LOCAL COVERAGE DETERMINATIONS

Proactive ophthalmic practices review the Local Coverage Determinations (LCDs) from their local Medicare Administrative Contractor (MAC) to ensure proper coding based on these guidelines. The policies address cover diagnosis codes, documentation requirements and approved Healthcare Common Procedure Coding System (HCPCS) codes (J-Codes) for billing intravitreal medications. Some MACs have unique requirements for billing. For example, bevacizumab (Avastin, Genentech) may be billed with J9035, J3590 or J3490 according to different policies. Periodically reviewing the LCDs and articles in your state can provide direction regarding the appropriate billing protocols for your region.

2 DIAGNOSIS LINK

Recognizing the approved diagnosis codes per medication type is the first step, but linking the correct diagnosis to the procedure on the claim is crucial. For example, inappropriately linking dry AMD instead of wet AMD can produce a claim denial, or even worse, a Recovery Audit Contractor (RAC) audit up to 3 years down the road.

3 CORRECT UNITS

Each medication should be billed with the appropriate number of units on the claim representing the actual dosage given. Consider ranibizumab (Lucentis, Genentech), which is billed with J2778. This HCPCS code represents a dose of 0.1 mg. When the dosage given is 0.5 mg, five units should be billed on the claim. With a dosage of 0.3 mg, three units should be used. Incorrectly billing one unit on the claim would reduce the reimbursement (by approximately $1580), and could trigger a data audit from the RAC.

4 PROPER DOCUMENTATION

Legible procedure notes for each injection including indication, medication, dosage and eye(s), along with a legible physician signature is necessary in any chart review. In addition, auditors are requesting consents, advance beneficiary notices when necessary, diagnostic tests with interpretation and reports, and signature logs. Specifically, auditors are looking for a documented plan of care with drug dosage, frequency, expected duration of treatment and any drug wastage. Performing internal audits is a proactive approach to ensure chart documentation is complete.

5 INVENTORY

Whether you use a manual log, computerized spreadsheet or a bar code system, maintaining your medication inventory is a valuable defense when presented with an audit. Necessary components of this system include an inventory log, patient log and inventory control policies.

The inventory log should show an accounting of all medications received and dispensed in a period of time and the net total should balance to the inventory on hand. All medication used should have corresponding paid invoices, excluding sample medications, which also should be identified. In addition, the patient log provides the patient name, date of service, medication, dosage, lot number, expiration date, and corresponding lot numbers for the list of medication used. The patient log entries should balance to a practice management report providing the total medication billed by HCPCS code.

Documenting your internal inventory control processes and the frequency of these audits can help demonstrate the practice’s commitment to accurate inventory documentation.

PREPARE FOR THE INEVITABLE

It’s reasonable to think of audits not in terms of ‘if,’ but ‘when.’ The best defense continues to be proper documentation, internal audits and commitment to current coding principles and education. This is an ongoing process but if addressed appropriately and consistently, the end result will be the best preparation for the inevitable. NRP