This year started with numerous changes to coding rules. Just when you think you have the new rules in place, though, things change again. As changes can occur in the reimbursement arena at any point during the year, it's extremely important to keep up with these ever-evolving policies.
Q: What happened to reimbursement for ophthalmic ultrasound codes?
A: In February, the Centers for Medicare & Medicaid Services published changes that significantly increased payment for these codes. Table 1 at right shows the national (unadjusted) allowable. Some providers have been paid at old rates. To date, there are no national instructions regarding claims resubmission for the revised ultrasound codes. A few individual carriers have posted instructions, including simply submitting a list of patients who require payment adjustments. Regardless, the payment adjustment will not be automatic. Contact your local carrier for current instructions.
Q: What happened to reimbursement for the IOLMaster?
A: When the code for the IOLMaster was initially added (January 2002) it was assigned a bilateral indicator of "2," meaning the procedure is defined as bilateral. Payment was based on 100 percent of the fee schedule amount for a single service. Later, the payment policy changed two more times. In February, it was changed to a bilateral indicator of "3," which makes it unilateral. The implementation date was April 5, 2004, retroactive to January 1, 2004. From March 1, 2003 until April 5, 2004 you should have been paid only once for 92136, even when used bilaterally. You can now seek additional compensation for the professional component of 92136 for the second eye for services performed between January 1, 2004 and April 5, 2004.
Q: Is it true that coverage for Ocular Photodynamic Therapy (OPT) has been expanded?
A: Ocular Photodynamic Therapy has also had some significant changes. Effective April 1, 2004, CMS has determined that, provided certain criteria are met, OPT with verteporfin (CPT codes 67221 and 67225, as well as HCPCS code J3395) will now be covered for AMD in two additional clinical instances: subfovial occult lesions with no classic choroidal neovascularization; and subfoveal minimally classic CNV associated with AMD.
These two new covered indications are considered reasonable and necessary only when:
• the lesions are small (four disk areas or less in size) at the time of initial treatment or within the three months prior to initial treatment; and
• when they have shown evidence of progression within the three months prior to initial treatment.
You must confirm this evidence of progression by documenting the deterioration of visual acuity (at least five letters on a standard eye examination chart); lesion growth (an increase in at least one disk area); or the appearance of blood associated with the lesion.
Q: Is the reimbursement for ambulatory surgery centers changing?
A: Yes. On January 1, 2004, Medicare's national allowable amounts for ASCs rolled back to the level in effect October 1, 2002 through September 30, 2003, and will be frozen through 2009.
Included on the Office of Inspector General's work plan in 2003 was a decision to determine if the $150 payment for an IOL to ASCs is reasonable, and if it relates to the actual cost of acquiring the lenses. The OIG found that $150 is not "reasonable and related to the cost." For the 12 months surveyed, 40 percent of IOL payments were in excess of the lens acquisition costs. The average IOL cost was $90.30 leaving an average of $59.70 over the cost on each lens.
The OIG recommended the payment for IOLs reflect the variation in type and costs. CMS agreed and will consider OIG comments when they revise the payment system for ASCs required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. These payment adjustments are scheduled to be implemented sometime between January 1, 2006 and January 1, 2008 (the complete report is available at:
Ms. Kennedy is an associate consultant with the Corcoran Consulting Group. Contact her at 1 (800) 399-6565 or firstname.lastname@example.org.