CODING Q&A

When Floaters Demand Treatment

SUZANNE L. CORCORAN, COE

Vitreous floaters can be annoying for patients, but most do not require treatment. For those times when they do, however, here is what you need to know.

Q. What is the medical rationale for treating vitreous floaters?

A. When a floater is significant — limiting vision and compromising the patient’s ability to function — surgical treatment may have merit. That is the exception, though, and not the rule. Most floaters require no treatment other than patient reassurance.

Q. Is laser treatment of vitreous floaters successful?

A. Maybe. A 2002 article¹ described moderate improvements in fewer than 40% of those treated with YAG laser. Earlier articles described higher success rates.^2,3 One Clear Vision, the UK-based Degenerative Vitreous Syndrome Association, indicates various success rates for five subtypes of floaters ranging up to 95%.⁴ And a published book on the subject references a formal study completed in March 2005.⁵

Q. Does laser treatment of vitreous floaters require FDA approval of the laser?

A. Probably not, but we have been unable to confirm it. According to an Ocular Surgery News article from 2007, “The FDA ruled that our study of laser treatment of vitreous opacities was a non-significant risk device study, and they ruled for the first time that a YAG laser could be used without special approval.”⁶

Some Nd:YAG lasers have specific FDA approval for related indications such as posterior membranectomy.

Q. What factors argue in favor of lasering vitreous floaters?

A. The physician may consider treating vitreous floaters with laser in cases where:

• The floaters cause a severe handicap

• Activities of daily living are seriously hindered

• Symptoms do not resolve over time

• The benefit of treatment outweighs the risk

As with any other surgical procedure, informed consent is critical. It encompasses the risks (such as possible retinal detachment), benefits, and alternatives to treatment.

Q. Is this procedure reimbursed by third-party payers?

A. There are few coverage policies on this topic. One, by Aetna, considers this treatment “experimental and investigational … because its effectiveness for these indications has not been established” and therefore not covered.⁷ Florida Blue Cross/Blue Shield says, “Laser vitreolysis is considered experimental or investigational … specifically vitreous floaters of the eye…”.⁸

Q. Do any CPT codes describe lasering vitreous floaters?

A. There are two CPT codes that apply: 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages) and 67299 (Unlisted procedure, posterior segment).

Use CPT 67031 when a visually significant opaque floater is severed from its attachment, allowing it to sink to the bottom of the vitreous and out of the line of sight. When severing does not occur, CPT 67031 does not apply, so CPT 67299 is the only valid choice.

Q. What are Medicare payment rates for 67031?

A. They are as follows:

• The national Medicare Physician Fee Schedule amount in the first half of 2015 for CPT 67031 is $392.23 if the procedure is performed in the office and $360.05 when performed in a national hospital outpatient department (HOPD) or ambulatory surgical center (ASC).

• The HOPD reimbursement is $443.46 in 2015.

• For ASCs, the 2015 Medicare-allowed amount is $243.09.

These amounts are adjusted by local indices, so actual payments will vary. In all cases, other third-party payers set their own rates, which may vary considerably from Medicare.

Q. What must we know about using 67299?

A. The use of unlisted codes poses administrative challenges. These include:

• There is no stipulated reimbursement schedule for physicians. Claims are evaluated and an appropriate payment rate is selected on a case-by-case basis.

• There is no published global period.

• Each claim stands alone; reimbursement for one case does not set precedent for the next.

• HOPD reimbursement is the same as for a YAG capsulotomy ($428.24).

• Within Medicare, unlisted codes are ineligible for ASC facility fee reimbursement.

Q. How frequently is laser vitreolysis performed?

A. Rarely. Within the Medicare program, CPT 67031 was reimbursed 3,023 times in 2013. The unlisted CPT code, 67299, was paid only 257 times in 2013. Ophthalmologists who perform this procedure frequently may attract unwanted attention as outliers. When a surgeon is challenged during post-payment review of a rarely performed procedure, lucid chart documentation is your best defense.

Q. If reimbursement is unavailable or uncertain, how should we proceed?

A. First, ask for prior authorization, if possible, from third-party payers. Where prior authorization is not possible, as in the Medicare Part B program, you should use a financial waiver form such as CMS’ s Advance Beneficiary Notice of Noncoverage (ABN). Medicare Advantage plans (Part C) don’t use the CMS ABN; check with the MA plans about waiver forms they require. RP

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