Q: Are there any new codes recently released that I should know about? If so, when do we use them?
We have the new ICD-10 codes and a couple of new HCPCS “J” codes. The J codes must be used immediately for Medicare; most other payers will follow suit. ICD-10 codes for 2023 were recently released by the Centers for Medicare & Medicaid Services. As always, they are for use each year, starting in October. That means you must begin using any new diagnosis codes or relevant coding guidance in October 2022—don’t wait until January of 2023 to start.
Q: What eye drugs are affected by the new codes?
CMS recently announced the expiration of two temporary C codes for a couple of relatively new drugs and their replacement with permanent J codes. In the first quarter “HCPCS Coding Cycle” announcement by CMS, they considered code applications and then issued new codes if the action was approved. For eye care, the codes affect Susvimo (Genentech) and Xipere (Bausch + Lomb)—and the new codes must be used as of July 1, 2022 for Part B Medicare. It’s likely that other payers will follow suit and demand the new codes, too—but some may lag a month or two, so you should check.
Q: What are the codes affected for Susvimo?
CMS noted the following Final Decision for the permanent J code Susvimo:
1) Establish new HCPCS Level II code J2779, “Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mg” Effective: 7/1/2022
2) Discontinue existing HCPCS Level II code C9093, “Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg” Effective: 6/30/2022
Q: How do I bill for Susvimo? Is it different in the office than in a facility?
Beginning July 1, 2022, billing will be as follows for Susvimo:
The recommended dose from the FDA package insert is 2 mg (0.2 ml of 100 mg/ml). That applies to both the expired C9093 code and the new J2779 code HCPCS code since each is written as “per 0.1 mg.” Importantly, you can be paid for the entire vial of this single-use vial (even for the wasted portion), but you’ll need two lines on the claim for the drug to accomplish that. You can’t put Susvimo on a single line with 100 units; that’s counter to already established CMS instructions when there’s billable wastage. Bill the administered dose as a line on the claim with 20 units and use a separate line for the unused (wasted) drug, which will show as a second line with JW modifier and 80 units.
No matter the location, the surgeon’s op note for the Susvimo injection needs to show the administered and wasted doses separately. It also must show the lot number and expiration date for the vial used. The NDC # (10-digit 50242-078-12) for SUSVIMO goes in box 19 of the CMS-1500 form.
If this is done at a facility, the facility bills for the drug (not the surgeon). Both the facility and the surgeon get to bill for the injection piece.
Q: What codes are used for Xipere?
For Xipere, the Final Decision and codes are as follows:
1) Establish new HCPCS Level II code J3299, “Injection, triamcinolone acetonide (Xipere), 1 mg” Effective: 7/1/2022
2) Discontinue existing HCPCS Level II code C9092, “Injection, triamcinolone acetonide, suprachoroidal (Xipere), 1 mg” Effective: 6/30/2022
Q: How do I bill for Xipere? Is it different in the office than in a facility?
Since the recommended dose in the FDA approval for Xipere is 4 mg (0.1 ml of the 40 mg/ml single use vial), billing will be as follows:
One line with the administered dose with four units, and a second line with the wasted drug with JW modifier and 36 units. As above, you can’t put all 40 units of the drug on a single line. Since you’re paid for an entire vial, the op notes should reflect the doses given and wasted as well as the lot number and expiration dates. The NDC for Xipere (10 digit 71565-040-25) goes in box 19. As with Susvimo above, if this is done at a facility, the facility (not the surgeon) bills for the drug. Both the facility and the surgeon get to bill for the injection piece.
Q: What are the 2023 changes I need to be aware of for ICD-10?
As noted above, any code changes or guidance goes into effect on October 1, 2022. Our “Eye and Adnexa” in ICD-10-CM (Chapter 7) actually has no new codes or even any code change guidance this time. Other chapters are affected, and your individual practice pattern affects whether you have codes to use or not. The most likely ones affecting eye care are in the Neoplasms (Chapter 2) and the Z codes (Chapter 21).
Q: I tried to order ICD-10 books and they won’t be available for a while. How can I get something I can show my staff?
You can access the codes for 2023 at the Medicare CMS.gov ICD-10 site. Once there, you’ll notice five downloadable files (four of these are ZIP files containing more than one item). There are two files for you to be especially aware of. The first one is the “FY 2023 ICD-10-CM Coding Guidelines” PDF. Anything in this file with a change from one year to the next is called out in bold, underline or italic typefaces, so it’s easy to see the differences for 2023.
The second useful download here is a ZIP folder titled 2023 Addendum. This Addendum folder contains five files. Of these, the most useful file is named “icd10cm_tabular_addenda_2023.” This file shows only the new or changed ICD-10 codes for 2023. You may notice Chapter 7 seems to be “missing” in this particular 2023 file. That’s to be expected, however, because as noted above, there are no changes. You can also download other files here until you get your books; they’re searchable PDF files if you save them electronically.
Q: What are the changes to Chapter 2 (Neoplasms)? I sometimes see patients with these conditions and have needed these codes.
The Tabular Addenda file mentioned above has some new guidance on when to use the primary versus a secondary site condition diagnosis. There’s more clarity for 2023 on primary and secondary site designation and when to use each. Some of the conditions you might see a patient for might not be a primary malignancy, so there’s been some confusion. The guidance under “Admission/Encounter for treatment of primary site” notes the following:
• “If the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, designate the primary malignancy as the principal/first-listed diagnosis.
• The only exception to this guideline is if the administration of chemotherapy, immunotherapy or external beam radiation therapy is chiefly responsible for occasioning the admission/encounter. In that case, assign the appropriate Z51.— code as the first-listed or principal diagnosis, and the underlying diagnosis … as a secondary diagnosis.”
Under “Admission/Encounter for treatment of secondary site” it states:
“When a patient is admitted because of a primary neoplasm with metastasis, and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.” This means that if you’re involved mostly in treating the secondary neoplasm, use that site as your first diagnosis on claims.
Q: What about the Z code changes? I don’t use them very often.
The changes are minor to Chapter 21 (Factors influencing health status and contact with health services) but as payers get more demanding, your use of these might need to increase. If you get payer denials after October 1, 2022, watch the denial codes to see if the payer is actually asking for additional codes as secondary diagnoses before accepting the claim. The small changes here that might affect us in eye care are:
• In the Z59.8 area: “Transportation insecurity,” “Financial insecurity,” and “Material hardship” have some greater specificity. While not commonly used, some of these might be relevant to some of your patients.
• The Z94.4 (use of insulin), Z79.84 (use of oral hypoglycemic) and Z79.85 (use of injectable non-insulin) codes are all unchanged—but there’s a new “Excludes2” instruction for each. CMS has long indicated that Excludes2 notes designate “… that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it’s acceptable to use both the code and the excluded code together, when appropriate.” This excludes2 note is a clue that both diagnosis codes might not apply to most encounters.
• There are a host of new Z79.6 codes that apply when the patient is on immunomodulators and immunosuppressants.
• There are many new (and more specific) “noncompliance” codes for patients and caregivers in the Z91 area. If they impact the care you deliver, you might consider using them.
1. CMS. CMS Healthcare Common Procedure Coding System (HCPCS) application summaries and coding recommendations first quarter, 2022 HCPCS coding cycle. https://www.cms.gov/files/document/2022-hcpcs-application-summary-quarter-1-2022-drugs-and-biologicals.pdf. Accessed 7/12/22.
2. FDA. Highlights of prescribing information for Susvimo. BLA 761197. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/761197s000lbl.pdf. Accessed 7/12/22.
3. CMS. MedLearnMatters MM9603 revised. JW Modifier: Drug Amount Discarded/Not Administered to any Patient. Effective date January 1, 2017. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdf. Accessed 7/12/22
4. CMS. 2023 ICD-10-CM. https://www.cms.gov/medicare/icd-10/2023-icd-10-cm. Accessed 07/12/22.
5. CMS. ICD-10-CM official guidelines for coding and reporting FY 202 2023 (October 1, 2022 -September 30, 2023). 2023 ICD-10-CM. https://www.cms.gov/medicare/icd-10/2023-icd-10-cm. Accessed 07/11/22.
Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at firstname.lastname@example.org.