Fact Sheet for Documenting the Need for Photodynamic Therapy (PDT)
By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement, and Joy Woodke, COE, OCS, OCSR, Academy Coding and Practice Management Executive
Because of the pandemic, CMS suspended audits of practices on March 30, 2020, but allowed them to resume on Aug. 3, 2020. At the time, CMS said that “providers should discuss with their contractor any COVID-19-related hardships they are experiencing that could affect audit response timeliness.”1 If you are granted an extension, save the written confirmation of it.
Auditors zeroing in on PDT therapy. Retina practices across the country have reported receiving requests for documentation to support the need for photodynamic therapy (PDT).
Noncovered indications. CMS has explicitly said that PDT isn’t covered for atrophic (“dry”) age-related macular degeneration (AMD) or for choroidal neovascularization (CNV) lesions that are juxtafoveal or extrafoveal. Also, initial treatment isn’t covered if you can’t obtain fluorescein angiography (FA).
Re-treatment. Re-treatment with PDT is considered reasonable and necessary if, on reexamination, the ophthalmologist finds leakage from classic CNV on FA.
Use of either OCT or FA to assess treatment response is permitted for claims with dates of service on or after April 3, 2013.
Coding. To report PDT for CNV, you can use CPT code 67221 for the first eye and, if treating the second eye at the same session, use add-on code 67225.
Use HCPCS code J3396 to bill for Visudyne (verteporfin). The billable unit is 0.1 mg, and a 15-mg vial contains 150 billable units. Report the number of units injected and, since it is a single-use vial, use modifier –JW on a second line to report how many units were wasted.
FURTHER READING. “Injectable Drugs, Part 1—How to Get Reimbursed for a Multidose Vial” (Savvy Coder, June 2018) and “Part 2—Correct Coding for Single-Use Vials” (Savvy Coder, July 2018).
1 www.cms.gov/files/document/provider-burden-relief-faqs.pdf. Accessed Feb. 2, 2021.
Pretherapy checklist. Document the following before therapy begins:
▢ CNV membrane (CNVM) secondary to AMD
▢ CNVM under the geometric center of the foveal avascular zone
▢ Evidence of classic CNVM on FA
▢ Area of classic CNVM at least 50% of the area of the total neovascular membrane
When is PDT covered? Effective April 1, 2003, PDT may be covered for:
▢ Subfoveal occult with no classic CNV associated with AMD
▢ Subfoveal minimally classic CNV (where the area of classic CNV occupies <50% of the area of the entire lesion) associated with AMD
Important caveat: These two indications are considered reasonable and necessary only when: The lesions 1) are small (4 disc areas or less in size) at either the time of initial treatment or within three months prior to initial treatment; and 2) have shown evidence of progression within the three months prior to initial treatment.
Procedure note. Your procedure note should document the following:
▢ Diagnosis supporting medical necessity and appropriate indication for use
▢ Relevant diagnostic testing services within the policy guidelines (FA, OCT)
▢ Physician order including medication name, dosage, and signature
▢ Route of administration, site of injection
▢ Dosage in mg and volume in mL
▢ Medication wastage recorded
▢ Consent completed
▢ Legible physician signature (paper chart records should include a signature log; if electronic, the electronic signature must be secure)
Sources: National Coverage Determinations (NCDs) for ocular PDT (Document ID#: 80.2.1), verteporfin (80.3.1), and PDT (80.2) are available at www.cms.gov/medicare-coverage-database. Academy 2021 Retina Coding: Complete Reference Guide is available at aao.org/store.