CODING Q&A

Reimbursement for Intravitreal Implants

BY SUZANNE CORCORAN, COE

Ophthalmologists use several different FDA-approved intravitreal implants designed for sustained release of their pharmaceutical load. These include: Retisert (fluocinolone acetonide, Bausch + Lomb, Bridgewater, NJ),¹ Vitrasert (ganciclovir, Bausch + Lomb),² and Ozurdex (dexamethasone, Allergan, Irvine, CA).³ These implants have different indications, different sizes, different implantation techniques, and different reimbursement. Many more sustained release drug implants for the eye are in development.⁴

Scientific literature and third-party payer policies^5-7 support the value of intravitreal corticosteroid implants and provide for coverage of Retisert for long-term control of uveitis, and for Ozurdex for short-term control. Vitrasert is indicated for the treatment of AIDS-associated cytomegalovirus (CMV) retinitis and generally is covered under a narrow set of guidelines.^8,9 Let’s review the relevant coverage guidelines here.

REIMBURSEMENT BASICS

Claims for reimbursement of the surgical service include a CPT code and a HCPCS code. The CPT code describes the implantation technique, and the HCPCS code describes the implant (Table 1). On a CMS-1500 claim form, box 24G reports the number of units of the supply. For Vitrasert and Retisert, use one unit for an implant, but for Ozurdex the HCPCS code describes 0.1 mg, yet the dosing is 0.7 mg, so report seven units on the claim.

THE PHYSICIAN-EFFORT FACTOR

CPT 67027 describes “Implantation of intravitreal drug delivery system (eg, ganciclovir implant) includes concomitant removal of vitreous” while CPT 67028 describes “Intravitreal injection of a pharmacologic agent (separate procedure).” The physician work is greater for 67027 than 67028 for several reasons, and the relative value units reflect this difference; 25.26 RVUs and 2.97 RVUs, respectively. First, a pars plana incision for implantation of Retisert or Vitrasert is larger (3.5-5.5 mm) than the puncture necessary for an injection.¹⁰ In contrast, Ozurdex is injected via a 22-gauge needle (Figure 1, page 14).¹¹

Figure 1. Ozurdex has a <0.4-mm diameter, the inside dimension of a 22-gauge needle.

Consequently, the physician effort to manage vitreous prolapse is considerably more for implantation through pars plana incision than injection. This occurs because of the relatively larger implant size of either Vitrasert or Retisert vs Ozurdex (Figure 2, page 14).

Figure 2. Relative sizes of intravitreal implants.

Second, the presence of tabs on Vitrasert and Retisert (Figure 3, page 14) is significant and permits suturing these implants to the sclera within the posterior chamber, while Ozurdex is free-floating.

Figure 3. Retisert measures 3 mm x 2 mm x 5 mm with suture tab.

Finally, closure of a 3.5-5.5 mm surgical wound entails more physician work than a self-sealing puncture following injection.

SETTING CONSIDERATIONS

For all of these reasons, implantation of Vitrasert or Retisert is usually performed in a hospital outpatient department (HOPD) or ambulatory surgery center (ASC) while implantation of Ozurdex is commonly performed in-office. Further, 67027 is assigned a 90-day postop period consistent with a major surgery and 67028 has zero postop days consistent with a minor surgery.

When performed in a HOPD or ASC the 2014 national Medicare payments to the facility are in Table 2. Payment rates for the pharmaceutical supply are established quarterly by CMS.¹²

The payment rate is $195.92 for one unit; seven units are $1,371.44.

While all of these products are intravitreal implants designed to provide sustained release of their pharmaceutical load, their differences are significant, and so is the coding and reimbursement. RP

REFERENCES