By David B. Glasser, MD, Academy Secretary for Federal Affairs, and Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
Corneal cross-linking (CXL) can stop the progression of keratoconus and ectasia following refractive surgery. While CXL has generated much excitement, you must tread carefully when seeking payment.
Despite FDA approval for CXL, reimbursement is not straightforward. For many years, U.S. ophthalmologists performed CXL on an experimental basis under institutional review board (IRB) control while waiting for U.S. Food and Drug Administration approval. Although approval arrived in April 2016, adopting the technology can still be a challenge. Avedro’s KXL system, which is the only FDA-approved modality for performing CXL, uses a high-cost medication. It is therefore imperative that you understand the vagaries of CXL reimbursement.
Use Category III Code 0402T
CXL doesn’t yet have a Category I Current Procedural Terminology (CPT) code. Instead, it has a Category III CPT code: 0402T Collagen cross-linking (including removal of the corneal epithelium and intraoperative pachymetry when performed).
Category III versus Category I CPT codes. Category III codes are used for emerging technologies and new procedures. They are temporary codes that will be either upgraded to a Category I code or discontinued altogether. Category III codes have not been valued by the Relative Value Scale Update Committee (RUC), which means payment is at the payer’s discretion.
Coding for the medication. HCPCS codes—also known as Category I, Level II codes—are 5-character alphanumeric codes that are used to document injectable solutions, supplies, glasses, contact lenses, and screening. Avedro did apply for a unique HCPCS code for Photrexa (riboflavin), the medication used with the KXL system. The application was denied last fall. Avedro plans to reapply for a HCPCS code for the medication. Until then, practices should submit HCPCS J3490 Unclassified drug,1 with a notation that indicates the medication’s name in Box 19 of CMS 1500 form. As with all medications, you should submit the National Drug Code billing identifier on the claim; this is 025357-0023-01 for Photrexa and 025357-0022-01 for Photrexa Viscous. A copy of the invoice for the medication must be submitted along with the claim.
New—A Retina-Specific OCS Exam
On April 2, the Academy launches the Ophthalmic Coding Specialist Retina (OSCR) exam, the first of its kind. Physicians and staff can use this unique testing opportunity to ensure that their coding knowledge is current, and by being up-to-date, they can enhance the financial health of their practices. To learn what topics are covered, see this month’s Academy Notebook. If you pass the exam, you’ll earn a 3-year certificate and the privilege of including “OCSR” after your name.
For more information, visit aao.org/ocs.
Commercial Carrier Coverage
While existence of a CPT code does not guarantee coverage by commercial carriers, there has been a rapid adoption of positive coverage policies for CXL throughout the United States. At time of press, more than 30 carriers—including Aetna,2 Kaiser Permanente,3 and many of the Blue Shield plans—have published positive coverage policies.
What you should do when a plan has a positive coverage policy. If your patient’s insurance has a positive coverage policy and you participate with the plan, you should not bill the patient in anticipation that the insurance pay-ment will not cover the entire cost of the procedure and drug. Doing so would most likely be a violation of your contract. Don’t bill the patient untilthe payer has processed the claim. The remittance advice will indicate any outstanding amount that is the patient’s responsibility.
What you should do when a plan has a negative coverage policy. If plans have a published negative coverage policy, you may collect from the patient.
What you should do when a plan has no published policy. Some plans have no published policy, but you cannot assume that this means noncoverage. If you collect from a patient and the patient then submits the claim herself and obtains coverage, you may have to refund the fees that you collected. It is of paramount importance to contact the carrier and ask for preauthorization before performing the procedure. When you request preauthorization, remember to ask what the allowable would be. This is because the insurance reimbursement may be lower than expected, and appeals after the claim has been underpaid require a great deal of work. It is less difficult to negotiate for a higher allowable before submitting the claim.
Protect Your Practice
In summary, here’s the good, the bad, and the ugly of CXL reimbursement.
Realize that it is good news that patients can benefit from this procedure and that many commercial insurance plans are covering it.
The bad news is that we still have more work to do in educating carriers on fair reimbursement for this procedure.
Protect your practice from any ugly repercussions by doing your homework prior to performing these procedures so that you do not lose money or potentially violate the terms of your insurance contract.
If, in the future, CXL is promoted from a Category III code to a Category I code, coverage and valuation for both the procedure and the riboflavin will be revisited.
1 2017 HCPCS Level II, Professional Edition, 2017 Elsevier.
2 Aetna Coverage Policy available at: www.aetna.com/cpb/medical/data/1_99/0023.html. Accessed Jan. 6, 2018.
3 Kaiser Permanente Coverage Policy available at: https://provider.ghc.org/all-sites/clinical/criteria/pdf/crosslinking.pdf. Accessed Accessed Jan. 6, 2018.