Q. What is the new laser treatment for age-related macular degeneration?
A. Treatment of dry AMD with photocoagulation is a relatively new procedure with limited utilization. It involves thermal laser photocoagulation in eyes with visually significant central soft drusen and consists of a scatter of perifoveal laser applications normally avoiding direct treatment of drusen. In 2000, HCPCS code G0187 was established for the procedure. It was replaced by CPT Category III code 0017T in 2003. The incidence of the procedure is minimal; Medicare paid for it only 88 times in 2002 in just three states: Florida, Michigan and Oklahoma.
The laser treatment utilizes Category III code 0017T, Destruction of macular drusen, photocoagulation. Reimbursement for Category III codes is at the carrier's discretion. The Medicare Physician Fee Schedule includes allowable amounts for Category I codes. In order for 0017T to become a Category I code, CPT says, "It must be performed by many health care professionals in a clinical practice in multiple locations and that FDA approval, as appropriate, has already been received." Neither Category I nor III, however, assures reimbursement, which is assessed case by case. An Advanced Beneficiary Notice should be completed for Medicare beneficiaries. For non-Medicare patients, request preauthorization before providing services, and have a waiver completed should payment be denied. The ABN or waiver facilitates collection from the patient.
Q. How is the wet for of age-related macular degeneration treated?
A. Academy of Ophthalmology Preferred Practice Patterns recommend treatment for wet AMD or exudative senile macular degeneration, involving photocoagulation and/ or photodynamic therapy to treat the choroidal neovascularization. New laser treatment options include Transpupillary Thermotherapy and feeder vessel therapy.
Some of these are reimbursed by third-party payers. The CPT codes for the treatments are :
• CPT 67220 Destruction of localized lesion of choroid (e.g., CNV); photocoagulation (e.g., laser), one or more sessions. The utilization of 67220 for treating CNV is greater than any other treatment for AMD. Medicare and other third party payers commonly cover photocoagulation (67220) of extrafoveal and juxtafoveal lesions.
• CPT 67221 Destruction of localized lesion of choroid (e.g., CNV); PDT (include intravenous infusion). Historically, PDT therapy was covered for patients with > 50-percent classic subfoveal CNV. In April 2004, CMS expanded the National Coverage Decision to include: 1) subfoveal occult with no classic CNV associated with AMD and 2) subfoveal minimally classic CNV associated with AMD.
• CPT 67225 Destruction of localized lesion of choroid (eg, CNV); PDT, second eye, at single session is used on rare occasions when PDT is delivered bilaterally on the same date of service. When this scenario occurs, 67221 represents treatment on the primary eye and 67225, the fellow eye. The second eye pays significantly less than the first, due to a single infusion and limited additional time and effort. The same requirements for lesion location and type remain.
• Category III code 0016T, Destruction of localized lesion of choroid (eg, CNV), traspupillary thermotherapy. TTT causes closure of CNV, reducing the submacular fluid. Reimbursement for Category III codes is at the carrier's discretion.
• HCPCS code G0186, Destruction of localized lesion of choroid (for example CNV); PDT, feeder vessel technique (one or more sessions). FVT used to treat both occult and classic CNV. Feeder vessel treatment uses highspeed indocyanine green imaging to locate the feeder vessel combined with minimal-intensity laser treatment to reduce the blood supply to the CNV lesion. Reimbursement for FVT is also at carrier discretion.
Q. Can patients be billed for treatments not reimbursed by insurance?
A. Patients may elect to proceed with a treatment and pay for it personally. An ABN is required before treatment to inform the patient that his insurance may not cover the service and why. The patient signs the form confirming that he will pay for the treatment in this instance.
What is meant by "one or more sessions" in the CPT definition of 67220?
For certain laser procedures , the rule defines one payment for the surgeon regardless of how many times the patient receives the same laser treatment in the defined global period. The rule applies to professional services but not facility fees.
Q. What documentation is requireed for laser procedures?
A. Documentation requirements are similar for all laser procedures. The chart note contains the rationale or medical necessity of the procedure. The laser operative report should include: indications for surgery; pre- and postop diagnoses; manner in which surgery performed (e.g., spot size, wavelength, energy); discharge instructions; and physician's signature. The patient's consent may be included with the operative report or as a separate form.
For information on the PDT NCD, visit the CMS website: http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103c1_Part1.pdf.
Mr. Mack, COMT, CPC, COE, is an associate consultant with Corcoran Consulting Group, corcoranccg.com. Contact him at 1 (800) 399-6565 or email@example.com.