New Year, New Codes: Time to Revisit Your Practice’s Internal Resources

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One challenge of ophthalmic coding is that the rules are fre­quently in flux. To avert claims denials, you should look out for any changes and, when necessary, update your practice’s internal coding resourc­es, such as cheat sheets and superbills.

Here’s an overview of what’s new for ophthalmology, along with tips for the review of your practice’s resources.

What’s New for CPT?

When you are billing for a new treat­ment, what is the most appropriate CPT code? The answer can be a moving target. Initially, you may need to use an “unlisted” CPT code, but you should watch to see whether the AMA’s CPT Editorial Panel assigns the treatment a temporary Category III CPT code. Category III codes help the Panel collect data on the usage of emerging technologies, services, and procedures. These data are then used to determine whether a permanent Category I CPT code is needed.

Category I CPT code 67516 for suprachoroidal injections. In 2023 suprachoroidal injections were reported with a Category III CPT code, 0465T, Suprachoroidal injection of a pharma­cologic agent (does not include supply of medication). Effective Jan. 1, 2024, this code was deleted and replaced with a Category I CPT code: 67516, Supracho­roidal space injection of pharmacologic agent (separate procedure) (Report medication separately). This is the code to use for injecting Xipere (triamcinolone acetonide injectable suspension).

Category III CPT code 0810T for subretinal injection. Until summer 2023, if you were billing for subretinal delivery of Luxturna (voretigene nepar­vovec-rzyl), you would have used an “unlisted” CPT code. Effective July 1, 2023, you should use the Category III CPT code 0810T, Subretinal injection of a pharmacologic agent, including vitrec­tomy and 1 or more retinotomies.

When to check for CPT updates. Category I CPT codes are updated annually, with changes going into effect on Jan. 1. Category III codes are updat­ed twice a year, in January and July.

What’s New for ICD-10?

In the most recent update of ICD-10 codes, which went into effect on Oct. 1, 2023, the changes relevant to ophthal­mology included added codes for:

• social determinants of health,
• muscle entrapments,
• chronic migraines,
• foreign body sensations, and
• nonproliferative and proliferative sickle-cell retinopathy. 

When to check for ICD-10 updates. ICD-10 codes are updated twice a year, with changes going into effect in April and October. The most significant up­dates usually take place in October.

What’s New for HCPCS?

As new drugs are introduced into ophthalmic practice, they are initially reported with a not otherwise classified (NOC) HCPCS code (Healthcare Com­mon Procedure Coding System) before graduating to a permanent HCPCS code. To ensure timely reimbursement, you should track this progression and report the new HCPCS code once it goes into effect.

In 2023, for example, Syfovre (pegcetacoplan) was approved by the FDA to treat geographic atrophy. Although you would have initially used a NOC HCPCS code, since Oct. 1, 2023, you should have been using its new perma­nent HCPCS code, J2781, Pegcetacoplan, intravitreal, 1 mg. Assuming you use the recommended dosage of 15 mg, you should report 15 units.

Watch for HCPCS updates. HCPCS codes are updated quarterly, in January, April, July, and October. The most cur­rent HCPCS codes for ophthalmic use are provided on the AAOE webpages for Coding for Injectable Drugs (aao.org/practice-management/coding/injectable-drugs) and Retina Practice Management and Coding (aao.org/practice-management/coding/retina).

What’s New With Modifiers?

During 2023, practices that adminis­tered drugs in a single-dose container had to start using modifier –JZ if zero amount of the drug was discarded (with zero being defined as less than 1 billing unit). Although CMS announced the new modifier in November 2022, the agency scheduled an extended timeline for its implementation: –JZ went into effect on July 1, 2023, and from Oct. 1, 2023, carriers were instructed to return claims as unprocessable if modifier –JZ isn’t used appropriately. It is imperative that all your internal guides and pro­tocols have been updated with instruc­tions for modifier –JZ. For more on –JZ, see “Meet Modifier –JZ: A Quick Guide to –JW’s New Counterpart” (Savvy Coder, September 2023).

When to check for modifier up­dates. CMS doesn’t often create new modifiers. Look for new modifiers in the AMA’s CPT Professional Edition or in the Physician Fee Schedule, which are published in the fall, with the mod­ifier taking effect either the following January or, as was the case with modifier –JZ, on a delayed timeline.

What’s New With NCCI Edits?

The National Correct Coding Initiative (NCCI) lists pairs of CPT codes that can’t be billed together. These pairs of codes are referred to variously as NCCI edits, CCI edits, or bundled codes.

When to check for NCCI updates. CMS updates and publishes NCCI edits quarterly, in January, April, July, and October. If your practice uses internal guides that summarize the bundled codes for frequently used procedures— such as your most common testing services or surgical procedures—you should double-check them each quarter to make sure they match the latest NCCI edits. Historically, the most significant NCCI changes occur in Jan­uary, and that month’s lists will include any new CPT Category I or Category III codes as appropriate.

Confirm Practice Compliance

Although the new year should prompt a comprehensive audit of all your practice’s resources, you also need to periodically review them for coding accuracy throughout the year.

Vendors’ code libraries. EHRs and practice management systems include libraries of CPT Category I and III codes, ICD-10-CM codes, and HCPCS codes. Some vendors will provide sys­tem updates to import changes to those codes. You should confirm that any up­dates include the necessary ophthalmic coding changes and that they appear accurately throughout your EHR and/ or practice management system.

Superbills. Whether your superbills are electronic or on paper, you should review them to verify that they reflect all the relevant changes. Superbills commonly use shortened versions of the code descriptors, and you should confirm that any abridged descriptors accurately represent the full official ver­sions. You should also review any ICD- 10 codes listed in the superbill to make sure that they represent the highest level of specificity, including laterality and disease staging, if applicable.

Cheat sheets. Many practices create internal quick reference guides to make coding more efficient. These can, for example, help billers to find the appro­priate CPT codes for surgical proce­dures and quickly identify if two codes are bundled under NCCI. However, such cheat sheets can quickly become outdated. To check that your quick references are up to date, start with the Academy’s 2024 coding products and also use the many online resources that are available (see below).

Educate the team. As coding changes occur, make sure that you communicate any updates to the entire ophthalmic team.