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Savvy Coder: Coding & Reimbursement
Know the New Codes for Amniotic Membrane Transplantation
By David B. Glasser, MD, Academy Health Policy Committee, Kim Ross, OCS, CPC, Academy Coding Specialist, and Sue Vicchrilli, COT, OCS, Academy Coding Executive
 
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In a big change for cornea coding, the 2011 Current Procedural Terminology (CPT) now has three codes for amniotic membrane transplantation—65778, 65779 and 65780 (see box)—up from one last year. This trio of codes reflects the fact that there are several ways to tackle the procedure, some requiring more skill and effort than others. The change has prompted a slew of questions among billers.

Q. What are the global periods and typical allowables for 65778 and 65779?

A. They each have a 10-day global period. In both cases, the typical allowable depends on whether you perform the procedure in the office or in a facility: 65778—$947 (office) and $57 (facility); 65779—$857 (office) and $219 (facility).

The cost of the tissue is built into the practice expense when performed in the office, thus the higher allowable. When the surgery is performed in a facility, the facility must pay for the tissue, as a “pass through” for amniotic membrane was revoked.

Q. Can 65778 and 65779 be billed when performed in conjunction with CPT codes 65430 cornea scraping, 65435 removal of corneal epithelium and/or 65780 ocular surface reconstruction?

A. No. CPT specifically states that the codes are not to be billed together.

Q. Which code should we use when using tissue glue?

A. CPT specifies that you should use 66999—which is the code for an unlisted procedure of the anterior segment—for placement of amniotic membrane using tissue glue.

Q. If a pterygium is removed and, rather than placing an autograft, a single sutured layer of amniotic membrane is applied, how should this be coded?

A. In the office setting, 65779–eye modifier should be listed first because it has the highest allowable, followed by CPT code 65420–51–eye modifier, which is the code for pterygium excision without graft. When it is performed in the ASC, submit 65420–eye modifier first followed by 65779–eye modifier. Remember that many payers no longer require modifier –51, which indicates multiple procedures were performed in the same operative session.

Q. If a pterygium is removed and both an autograft and a single sutured layer of amniotic membrane are used (e.g., for a very large defect), how would this be coded?

A. If the surgery is performed in the office setting, use 65779–eye modifier and 65426–eye modifier for pterygium excision with graft. Payment will be 100 percent of the first procedure and 50 percent of the allowable for the second procedure. If performed in the ASC, 65426–eye modifier should be submitted first because in this setting 65426 has the higher allowable.

Q. How do we code for the ProKera ring?

A. Use 65778. When this procedure is performed in the office, the typical allowable is $947, which includes the supply of the ring. In the ASC, the physician allowable is $57.

Q. If a ProKera ring is inserted postoperatively within the global period of another cornea procedure, how should the doctor bill for this?

A. If planned prospectively, use 65778–58. Payment will be 100 percent of the allowable. You’ll need to begin a new 90-day global period. If not preplanned, submit 65778–78. Payment will be 80 percent of the allowable. Continue the global period of the original procedure.

Q. If LASIK is performed and the postoperative ProKera is for a medical reason, can a claim be submitted using 65778?

A. In the case of a medical complication that results from a noncovered procedure, payment is up to the individual payer coverage policy.

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A Trio of Codes

Cornea practices billing for amniotic membrane transplantation now have two new codes (“circle_15”) and one that has had a change to its description (“triangle_15”):

circle_15 65778 Placement of amniotic membrane on the ocular surface for wound healing; self-retaining

circle_15 65779 single layer, sutured

triangle_15 65780 Ocular surface reconstruction; amniotic membrane transplantation, multiple layers

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Q. If multiple layers of amniotic membrane are used in conjunction with pterygium surgery without an autograft, is it appropriate to submit both CPT code 65420 and 65780?

A. No. The appropriate code is actually 65426. This code’s descriptor—pterygium excision with graft—does not specify what material is used for the graft or how many layers are used. CPT code 65780 is for ocular surface reconstruction plus multiple sutured layers of amniotic membrane. The problem with using a combination of 65420 plus 65780 is that the physician would be paid twice for removing the pterygium. There is no code for multiple layer amniotic membrane transplantation performed as an add-on to another procedure. In that scenario, an unlisted procedure code would be used.

Q. How should we code when a single layer amniotic graft is used with sutures and glue?

A. Use 65779.

Q. How should we code for placement of amniotic membrane without reconstruction using self-retaining or single-layer suture technique?

A. For the self-retaining technique, use 65778; for the single-layer suture technique, use 65779.

Q. For multiple layers of amniograft used for ocular surface reconstruction, what is the proper code?

A. Use 65780.

Got another question about these codes? E-mail it to coding@aao.org.

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CodeQuest

In the next few weeks, Codequest—a half-day, state-specific seminar on coding—will be coming to Nebraska, Oregon, Texas and Washington.

To find out when Codequest comes to your state, visit www.aao.org/codequest.

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