Q: What are the correct reimbursement procedures for capsular tension rings?

A: Weakened zonular structures, whether  due to disease such as Marfan's or pseudoexfoliation syndrome, or to previous intraocular surgery, cannot withstand the natural stress of cataract extraction with intraocular lens implantation. A CTR provides additional support to the capsule for stability during phacoemulsification. As of October 23, 2003 the FDA approved the Morcher CTR. The Ophtec BV CTR was approved on April 27, 2004. Some other CTR models are not FDA-approved.

Q: What's the correct code for reimbursement for professional service?

A: CPT code 66982 is defined as: "Extracapsular cataract removal with insertion of an IOL prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phaco-emulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage."

Inserting the CTR during cataract surgery satisfies the definition, making 66982 appropriate. Medicare's national allowable for 66982 is $899 in 2004, roughly 34 percent higher than "routine" cataract surgery. This amount is adjusted by local indices, so actual reimbursement will vary.

Q: What should the chart document to support the medical necessity for a CTR?

A: Nothing published yet regarding specific documentation requirements. We recommend, however, that there be a discussion in the chart, prior to surgery, regarding clinical findings that increase the risk of loss of zonular integrity. Remember that management of complications that occur during surgery is included in the global fee for the initially planned procedure and cannot be billed separately.

Q: Is CTR separately billable and reimbursed?

A: Yes, when performed in an ambulatory surgery center. Under the Medicare law, a prosthetic device (such as CTR) is a Medicare benefit and deserves separate reimbursement when it is not specifically part of the ASC facility fee. A claim for CTR must be submitted by the ASC in which the procedure occurred; the surgeon cannot bill for it.

When submitting claims for separately billable prosthetic devices, a HCPCS code is required rather than a CPT code. The CTR does not have a distinct HCPCS code, so the miscellaneous code L8699 Prosthetic implant, not otherwise specified is used. Claims for miscellaneous codes generally require supporting documentation to facilitate payment. There is no Medicare reimbursement amount pre-defined for miscellaneous devices.

Unfortunately, as well, there is no separate claim when device is used in an HOPD. Under current Medicare regulations, the prosthetic device is included in APC 246 under the Outpatient Prospective Payment Services. The national payment rate for APC 246 is $1,254. This is adjusted by local wage indices.

Q: What are the indications for endolaser cyclophotocoagulation?

A: ECP is a modern, and perhaps less severe version of ciliary destruction than earlier transcleral cryotherapy and transcleral cyclophotocoagulation utilizing a diode laser. The most significant difference is that ECP has an internal approach and the others are external.

Medicare covers ECP when medically necessary. Use CPT code 66710, Ciliary body destruction; cyclophotocoagulation. This is the same code used for transcleral cyclophotocoagulation. Note that CPT does not specify an intraocular or extraocular approach for 66710.

Under current Medicare regulations, 66710 is eligible for Group 2 ASC reimbursement, effective April 1, 2004. The national allowable is $446; this amount is adjusted by local wage indices. If ECP is done in a HOPD, 66710 is included in APC 233. The national payment rate of $787 is adjusted by local wage indices.

Q: What is the global postop period for ECP?

A: Ninety days, and major surgery rules apply. Unlike other laser procedures, the "one or more sessions" rule doesn't apply to ECP. Therefore, in the unusual case where additional treatments are necessary, they are separately billed. Use Modifier -78 return to the operating room for a related procedure during the postoperative period.

To support the medical necessity for ECP, both peer review and third-party payers expect that non-surgical treatment options will be initiated before a decision is made for surgery. Failure of medical therapy should be documented in detail in the patient's record. The decision that medication has failed may be based on financial constraints, compliance issues, poor results or adverse reactions. Notes to that effect support the medical necessity of surgery.

Though ECP employs an endoscope, it not appropriate to bill 66990 in addition to 66710. CPT specifically designates which codes are eligible for the add-on code, 66990, use of ophthalmic endoscope; 66710 is not listed. 

Ms. Kennedy is a senior consultant for Corcoran Consulting Group. Contact her at pkennedy@corcoranccg.com