CODING Q&A

Big Changes for PRP Code

SUZANNE L. CORCORAN, COE

Look out, retinal specialists — 2016 brings major changes to reimbursement of panretinal photocoagulation (PRP), CPT code 67228.

Q. What changed for PRP coding?

A. Effective Jan. 1, 2016, the CPT code descriptor for PRP changed. It now reads, “Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation.” Previously, the descriptor included the phrase, “1 or more sessions.” Additionally, the Centers for Medicare & Medicaid redefined the global surgery period for 67228. Instead of 90 days, it is now 10 days.¹ This has major implications for physicians who do this procedure.

The change to a 10-day global surgery period means that Medicare now defines this code as a minor procedure. As such, modifier -25 rules apply and an exam on the same day as 67228 is included in the surgery fee — unless the exam is for a distinct and separately identifiable service.² Modifier -57 doesn’t apply for the same-day exam resulting in the decision for surgery.

Physicians frequently perform PRP in stages — often two or three sessions a few weeks apart — because application of the laser is uncomfortable for patients when too much is attempted at once. When PRP had a 90-day global period, the code was billed once at the first session, and repeat applications of the laser were not billed within the 90-day global period. Now that 67228 has a 10-day global period, each session outside the 10 days is billed separately.

Q. What about PRP performed in the last quarter of 2015?

A. The 90-day global period still applies to PRP performed in October, November, or December. Do not bill again for PRP until the global periods for the affected eyes expire.

Q. How about reimbursement?

A. First, a little history. You know that the Sustainable Growth Rate (SGR), with its annual potential across-the-board cuts, was repealed in 2015. However, prior to that, in 2014, Congress passed the Protecting Access to Medicare Act (PAMA). This set a target for adjustments to misvalued procedure codes for calendar years 2017-2020 of 0.5% of the estimated expenditures under the Medicare Physician Fee Schedule (MPFS) for each of the four years.

The Achieving a Better Life Experience Act of 2014 (ABLE) then moved up the timeline and target to apply the adjustments for 2016-2018. It set a target adjustment of 1.0% for 2016 — twice as much as PAMA — and kept the instruction to identify misvalued codes.

Along with many other codes, CPT 67228 was identified by CMS as misvalued. Codes with this designation required CMS to reassess payment rates. As a result of this review, payment for 67228 was reduced from a national allowable of $1,016.20 to $345.15 — a 66% drop.

The ABLE Act also sought to mitigate large MPFS cuts by requiring that CMS phase in any reduction of more than 20% to a specific code. The phase-in period is two years; this results in spreading the effect of large MPFS cuts. However, it was determined that the phase-in did not apply when the definition of a code changed significantly. Changing the global period of the procedure was deemed to be a significant change, so the entire cut to the allowable took effect in 2016.

A 66% cut is a devastating change — or would be — but there is some good news. As noted above, CPT 67228 is no longer defined as “1 or more sessions” and is now a minor procedure with a 10-day global surgery period. As such, each session outside of the 10-day global period may be billed separately. This means that two sessions (combined) have reimbursement of $690.30, a 32% reduction from 2015 rates — still a large cut but not nearly as bad. If three sessions are performed, the combined reimbursement is $1,035.45, a 2% increase.

Dividing PRP laser treatments into more sessions merely for the sake of reimbursement would be unethical and poor patient care, as well as abusive of the Medicare system. However, when it is clinically appropriate to perform PRP in multiple sessions, it is comforting to know that net reimbursement doesn’t suffer as much as it otherwise might have. RP

NOTES