A. Most patients are treated with reassurance, as most floaters require no treatment.
Q. Are floaters ever treated with surgical intervention? Is laser treatment of vitreous floaters successful?
A. Yes. Surgical treatment may have merit when a floater is significant, limiting vision and compromising the patient’s ability to function. This approach is the exception and not the rule. Treatment may or may not be successful. A small number of articles exist, dating back to between 2002 and 2005, describing some success with this treatment.
Q. Are there specific documented factors in the patient’s medical record to support laser treatment vs. not treating with lasers?
A. As with many ophthalmic surgical procedures, the medical record should indicate that there is a severe handicap, the patient’s activities of daily living are seriously hindered by the floaters, the patient has had symptoms that have not resolved over time and the physician and patient have determined that the benefits of laser treatment outweigh the risk.
Q. Will third-party payers cover laser treatment for vitreous floaters?
A. Maybe. Unfortunately, very few coverage policies exist on this treatment. Some payers consider the treatment “investigational and experimental” and therefore it is not covered. It’s best to confirm coverage before treatment.
Q. Are there any CPT codes describing this treatment?
A. Yes, actually. CPT code 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages) and 67299 (Unlisted procedure, posterior segment) both apply to lasering vitreous floaters. Use CPT 67031 when a visually significant opaque floater is severed from its attachment, allowing it to sink to the bottom of the vitreous and out of the line of sight. When a floater is vaporized by the YAG laser, rather than severed, CPT 67031 does not apply, so you would use CPT 67299 instead.
Q. How frequently are these codes utilized? Will the frequent use of these codes attract attention from Medicare?
A. These codes are rarely used. Medicare data from 2011, the most recent year available, indicates CPT 67031 was reimbursed 3,014 times; this number is actually lower than it has been in prior years. The unlisted CPT code 67299 was reimbursed 522 times in 2011, but remember that it applies to other procedures as well as lasering vitreous floaters.
It is worth noting that physicians who perform this procedure may attract unwanted attention from Medicare and other payers because they will be considered outliers and thus subject to extra scrutiny.
Q. What is the Medicare reimbursement rate for the procedure coded with 67031? Is the physician reimbursed differently if the laser is performed in an ambulatory surgery center or hospital outpatient department?
A. The national Medicare Physician Fee Schedule amount in 2013 for CPT 67031 is $401.81 if the procedure is performed in the office. If the procedure is performed in an ASC or HOPD, the physician will incur a site of service reduction. The 2013 national Medicare reimbursement rate for 67031 with the SOS reduction is $368.81.
Q. Is there facility reimbursement for an ASC or HOPD in CPT code 67031?
A. Yes. The national Medicare HOPD reimbursement is $410.79 in 2013. For ASCs, the 2013 national Medicare allowed amount is $230.51.
Q. Can we expect similar reimbursement rates from other third-party payers?
A. Possibly. In all cases, other third-party payers set their own rates, which may vary considerably from Medicare.
Q. Is there a postop period with CPT code 67031?
A. Yes. This laser is considered a major procedure and carries a 90-day global period. All other rules associated with major procedures apply.
Q. Are there challenges associated with the unlisted code 67299 if that code applies?
A. Numerous challenges do exist with all unlisted codes, including 67299:
• There is no stipulated reimbursement schedule for physicians;
• Claims are evaluated and an appropriate payment rate is selected on a case-by-case basis;
• There is no published global period;
• HOPD reimbursement for CPT code 67299 is the same as for a YAG capsulotomy ($410.79);
• Within Medicare, unlisted codes are ineligible for ASC facility fee reimbursement;
• Each claim stands alone; reimbursement for one case does not set precedent for the next.
Q. If coverage and reimbursement rates are uncertain, should we consider pre-authorization with third-party payers?
A. If a payer permits pre-authorization, you should always secure it in writing. They may or may not be willing to reveal reimbursement rates but you can ask. Unfortunately, Medicare will not preauthorize.
Q. If the patient has Medicare, how can we indemnify ourselves when coverage is uncertain?
A. You can ask the patient to sign an Advance Beneficiary Notice of Noncoverage prior to treatment. By signing an ABN, the Medicare beneficiary acknowledges that he has been advised that Medicare will probably–or certainly–not pay. The beneficiary also agrees to be responsible for payment, either personally or through another insurance, including Medicaid.
Q. If the patient has a commercial insurance, can we utilize an ABN in case insurance denies the claim?
A. Yes. You can develop a financial waiver form similar to Medicare’s ABN. This waiver informs the patient of potential financial liability and secures an agreement to pay for the service in the event of a denial. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.