This year there are some new CPT codes effective for use in eye care as of January 1, 2020. There are not as many as in past years, but they are important. Some common codes we’ve used have been deleted or altered in subtle ways. (Be sure to use codes and their related guidelines that are in effect for that date of service.)
Let’s review the new 2020 CPT codes that are important in eye care, and some of the im-
portant things to know about them.
Q: What are the CPT Category I code changes that go into effect on January 1 that might affect eye care?
A: Before we discuss the new codes being introduced, the following codes have been deleted and will no longer be available for use after December 31, 2019:
• 92225—Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial.
• 92226—Ophthalmoscopy, extended … ; subsequent.
• 20926—Tissue grafts, other (e.g., paratenon, fat, dermis).
Some codes are completely new. I’ve ordered them by which are likely to be used first and made small comments for clarity:
• 92201—Ophthalmoscopy, extended, with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral.
• 92202—Ophthalmoscopy, extended, with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral.
Importantly, this code pair is now paid once per patient instead of “per eye” (as the deleted codes were), and they’re divided based on the anatomy drawn, rather than on whether it’s a first drawing or a subsequent one.
• 66987—Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery … or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation.
• 66988—Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation.
66987 and 66988 are just like our current cataract/IOL and complex cataract/IOL codes, but are only used when concurrent endocyclophotocoagulation is done.
There are also new codes for online digital evaluations:
• 99421—Online digital evaluation and management service, for an established patient, for up to 7 days; 5 to 10 minutes;
• 99422—11 to 20 minutes;
• 99423—21 or more minutes.
CPT notes these are used solely for patient-initiated online evaluation services and can’t be used to pass along tests results, schedule visits,
postop checks, or other non E/M services. There are some other guidelines related to these three codes.
• 15769—Grafting, autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia).
Other codes are changed slightly (the underlined text is added for 2020):
• 66711—Cyclophotocoagulation, endoscopic, without concomitant removal of crystalline lens.
• 66982—Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery … or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation.
• 66984—Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation.
Many of the nasal/sinus endoscopy codes were modified slightly. Those codes are 31233, 31235 and codes 31292 through 31298. Most of these changes clarify the codes by moving words in the code descriptors.
The remote physiologic monitoring codes are also changing slightly. These aren’t commonly used now, but may grow in importance as patients use devices that create measurements that providers will need to manage over time. There is one revision and one new code in this area. (The new code has a “+” since it is an add-on code.)
• 99457—Remote physiologic monitoring treatment monitoring management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
• +99458—Remote physiologic monitoring treatment monitoring management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each subsequent 20 minutes.
Other than the scoring weight changing to 40 as mentioned, the reporting thresholds are increasing to 70 percent for both claims-based reporters and those using Registries or direct EHR reporting.
Q: Are there any other CPT code changes to be aware of?
A: There are some Category II code changes that affect eye care as well. Category II codes like those below are generally only used in the Quality Payment Program under the Merit-Based Improvement System (MIPS) for those reporting via claims-based methodology. If you are a claims-based MIPS reporter they will commonly be seen and used. Those who use registries or ACOs for QPP reporting in 2020 and after are impacted less. There are six changes—the even-numbered codes had revisions and the odd-numbered ones are new. The codes are now divided based on “with” and “without” evidence of retinopathy:
• 2022F—Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy.
• 2024F—7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy.
• 2026F—Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy.
• 2023F—Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.
• 2025F—7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.
• 2033F—Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy.
Q: What about other CPT codes, such as Category III codes?
A: Category III codes also underwent changes. These particular codes are released semiannually by the American Medical Association. This year there’s a new one affecting eye care that goes into effect on January 1, 2020:
• 0563T—Evacuation of meibomian glands, using heat delivered through wearable, open-eyelid treatment devices and manual gland expression, bilateral.
In addition to the one new code above, there is one deleted Category III code and one revised code affecting eye providers:
• Deleted code: 0341T—Quantitative pupillometry with interpretation and report, unilateral or bilateral.
(Not for use after December 31, 2019.)
• 0402T—Collagen crosslinking of cornea, including removal of the corneal epithelium and intraoperative pachymetry, when performed (Report medication separately).
(Effective as of July 1, 2019, now scheduled to sunset in December 2024.)
Q: I heard some HCPCS code have been released—and that one changed mid-year (for use on claims for July 1, 2019 and afterwards). Is that true? If so, what are those codes?
A: There are a number of significant changes in this area. The new HCPCS codes and changes are:
• C1839 —Iris implant
This is a new code; it’s currently only for use with Veo Ophthalmics’ product, the CustomFlex artificial iris. This has been FDA approved for sale since June 2018 but has mostly been used in clinical trials in the United States.
CMS has approved this product for “pass-through” device reimbursement status for three years beginning January 1, 2020. That will smooth payment for the device with Medicare claims, but you should check with non-Medicare payers for coverage and obtain prior authorization if possible.
• J7314—Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg [18 units are used on claims.]
• J7311—Injection, fluocinolone acetonide, intravitreal implant (Reti-sert), 0.01 mg [Use 59 units on claims.]
• J7313—Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg [Use 19 units on claims.]
Two of these HCPCS codes have pass-through status, which means they’re paid (usually only for three years) when used in facilities like ASCs and HOPDs. Those two codes are:
• J1097—Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml (Omidria).
Use four units on claims. (Pass-through status for the facility payment is due to completely expire on September 30, 2020, so separate payment after that date is unlikely.)
• J1095—Dexamethasone intraocular suspension 9%, intraocular, 1 microgram (Dexycu).
The drug has 517 micrograms, so be sure to use 517 units on claims for proper payment. This drug has a current pass-through status; that special status expires on September 30, 2021. The old C-code (C9048) for the drug was deleted in July 2019 when the J code was established.
Q: Any other drug changes in addition to the HCPCS codes above?
A: Yes, and this one’s important to those treating exudative age-related macular degeneration with the newly approved drug Beovu (brolucizumab-dbll 6 mg/0.05 mg injection, Novartis). There’s no current code for it, but it does have FDA approval and is being actively marketed in the United States. There will likely be a specific HCPCS code approved for use during the new year, but no other information is available at this time.
The FDA-approved package insert for brolucizumab notes the treatment is done via three monthly loading doses, then every eight to 12 weeks afterward. Beovu is approved for other indications in some other countries, and these may eventually be approved in the United States but, for now, it’s only approval here is for wet AMD. The intravitreal injection is coded via 67028 as expected. Here are the specifics regarding coding:
• J3490 or J3590 when office-based; C9399 for HOPD. Check with payers for their preferred code and obtain prior authorization if possible.
— Use the NDC # and drug name in Box 19 on claims; use 1 unit for now.
— The 10-digit NDC number for claims is 0078-0827-61; the 11-digit number is 00078-0827-61.
— Payers may require invoice for payment even if approved. The manufacturer has a patient-assistance program when patient cost is a con-cern.
— Consider the use of a financial waiver, due to the new drug’s cost and potential coverage issues.
Q: Are there any coding “bundles” that involve the new and revised codes?
A: That’s not known yet, since the quarterly release of the NCCI files for January 2020 wasn’t released as of this writing. CPT has already noted fundus photography shouldn’t be done with the new 92201/92202 extended ophthalmoscopy codes. The guidance on the online evaluation codes notes they aren’t for related office visits within seven days, so a bundle is likely. For all other codes, be sure to check.
Q: What about the physician reimbursement under Medicare for all these new codes?
A: The 92201/2 codes, if drawn bilaterally, will end up being paid significantly less than a bilateral use id 92225/6 in 2020. Medicare has also noted that the new cataract/IOL/ECP codes (66987 and 66988) are going to be contractor-priced for the surgeon instead of being set nationally by Medicare.
Importantly, for the surgeon (not the facility) the cataract and IOL codes 66982/66984 will be cut by about 15 percent for 2020. ECP (66711) also gets a large cut (-22 percent) if done without cataract/IOL. Other codes getting a significant reduction are:
• 65205 and 65210—Conjunctival FB;
• 92250—Fundus photography; and
• 92136—Optical coherence biometry w/IOL calculation.
Fluorescein angiography (92235) gets a 13-percent reimbursement increase in 2020.
CMS has authorized Medicare Advantage plans to implement “Step Therapy” for Part B drugs. Step Therapy is sometimes known as “fail first,” and usually requires that a drug fail before moving on to potentially more costly options.
Q: What are the biggest changes for facilities?
A: There are a few, and the news is a mixed bag. Payment to the ASC or HOPD goes up for upper lid blepharoplasty (15823), cataract/IOL (66982/66984), pars plana vitrectomy (67036) and the Xen gel implant (0449T).
In the Final Rule for facilities, Medicare mandated something that was never required before: prior authorization. While prior authorization is common for many payers for certain procedures, this is new territory for Medicare. Importantly, this is not true for all surgeries; it’s only for certain procedures when they’re performed in the HOPD setting. On the short list of procedures is CPT 15823. If you do all of your upper lid blepharoplasties in an ASC, then you won’t be affected.
Reporting for ASCs on quality measures remains simplified in 2020. Additionally, as of November 29, 2019, ASCs no longer have to require a comprehensive H&P within 30 days of surgery, and the requirements to have a transfer agreement with a hospital—and that surgeons operating in the ASC have hospital privileges there—were eliminated. The H&P issue is now under ASC and surgeon control and not a strict mandate by Medicare.
Q: What about changes to Medicare beneficiaries’ obligations and other administrative changes for my office?
A: The 2020 Medicare Part B deductible rose $13, to $198, so you’ll need to collect this greater amount beginning in January. New Medicare cards have been issued to all past beneficiaries. The transition period ends on January 1, 2020, so on that date you can use only the new MBI. Claims with the older numbers will be rejected.
Q: It seems I’m seeing more Medicare Advantage plan patients than ever before. Is it just me?
A: Although there are regional differences (Wyoming and Alaska have very low MA market penetration), and some have been high-MA states (HI, FL, HI, MN, OR, PA, and WI), Medicare Part C (Medicare Advantage) continues to grow. Importantly, Kaiser Family Foundation research and CMS report that about 40 percent of all eligible beneficiaries will likely be enrolled in an MA plan in 2020. This continues a steady trend of increasing MA plan coverage.
Q: Any other Part C issues I should know about?
A: Yes. CMS has authorized Medicare Advantage plans to implement “Step Therapy” for Part B drugs. Step Therapy is sometimes known as “fail-first;” it usually requires providers to document a trial (and failure) of a certain drug or therapy before moving onto potentially more costly options. This implementation of Step Therapy only applies to office-used (Part B paid-for) drugs never used on a beneficiary before; patients already on a drug and getting results get to remain on that drug, although continued prior authorization is likely to remain in play. REVIEW
Mr. Larson is a senior consultant at the Corcoran Consulting Group. Contact him at firstname.lastname@example.org.