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  • Savvy Coder

    The CPT and HCPCS Changes That Impact Coding in Ophthalmology

    By Cherie McNett, Academy Director of Health Policy, Michael X. Repka, MD, MBA, Academy Medical Director of Government Affairs, and Sue Vicchrilli, COT, OCS, Academy Director of Coding and Reimbursement
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    Each year, the American Medical Association updates its Current Procedural Terminology (CPT). In 2019, the most significant changes for ophthalmology include new codes for electroretinography and biopsies, plus a new HCPCS code for corneal cross-linking and new Category III codes. In the 2019 listings, a red dot (●) is used to flag new codes.

    The following changes impact all your payers, not solely Medicare Part B.

    ERG Testing

    To distinguish between the different types of electroretinography (ERG) testing that are now in use, CPT code 92275 ERG was deleted and replaced with two Category I, Level I codes (92273 and 92274) and one Category III code (0509T).

    ● CPT code 92273 ERG with in­terpretation and report; full field (i.e., ffERG, flash ERG, Ganzfeld ERG). The RVS Update Committee (RUC) had determined that this new code should be assigned a work Relative Value Unit (wRVU) of 0.80, but CMS disagreed and assigned it a wRVU of 0.69. The typical allowable is $138. The technical component (–TC) requires general supervision. The National Correct Coding Initiative (CCI) bundles five codes with 92273: 99211, 99446, 99447, 99448, and 99449.

    ● CPT code 92274 ERG with interpretation and report; multifocal (mfERG). CMS assigned 92274 a wRVU of 0.61, despite the RUC recom­mending a wRVU of 0.72. The typical allowable is $93. The technical compo­nent requires general supervision. CCI bundling for this code is the same as for CPT code 92273.

    Note: New testing services might not be immediately recognized by commercial payers. (For example, some commercial payers implement updates at the start of their fiscal year instead of at the start of a calendar year.)

    ● 0509T ERG with interpretation and report, pattern (PERG). This Category III code was created specifically for ap­propriate reporting of this technology, and it has significant differences from the historical ERG code. CCI bundling is the same as for CPT code 92273. (See this article online for Category III code payment policies.)

    Biopsies

    CPT codes 11100 Biopsy of skin; single lesion and the add-on code +11101 for each separate/additional lesion have been deleted. They have been replaced with a new family of biopsy codes that are defined by technique:

    • Tangential biopsy (e.g., shave, scoop, saucerize, and curette)
    • Punch biopsy involves use of a punch tool to get a full-thickness cylin­drical sample of skin, and it includes simple closure.
    • Incisional biopsy involves use of a sharp blade to obtain a full-thickness sample of tissue via a vertical inci­sion or wedge, and it includes simple closure.

    The three new primary codes each have an add-on code. The add-on code should be listed separately, in addition to the code for the primary procedure.

    ● CPT code 11102 Tangential biopsy of skin; single lesion.

    ● +11103 each separate/additional lesion. This is 11102’s add-on code.

    ● CPT code 11104 Punch biopsy of skin; single lesion.

    ● +11105 each separate/additional lesion. This is 11104’s add-on code.

    ● CPT code 11106 Incisional biopsy of skin; single lesion.

    ● +11107 each separate/additional lesion. This is 11106’s add-on code.

    Example. If the physician performs a punch biopsy and two tangential biopsies, the claim submission in­cludes three codes—11104, 11102, and +11103—and each would have a 1 in the unit field. It is enough to indicate the number of units; you don’t need to append –RT, –LT, –E1, or –E4.

    Note: When the biopsy is more than superficial, report CPT code 67810 Incisional biopsy of eyelid skin, including eyelid margin.

    New Category III Codes

    In addition to 0509T, mentioned above, there are three new Category III codes that ophthal­mologists should know about.

    ● 0506T Macular pigment optical density measurement by heterochromatic flicker photome­try, unilateral or bilateral, with interpretation and report.

    ● 0507T Near infrared dual imaging (i.e., simultaneous reflective and transilluminated light) of meibomian glands, unilateral or bilateral, with interpretation and report.

    ● +0514T Intraoperative visual axis identification using patient fixation. This is an add-on code to cataract surgery codes 66982 and 66984, and it should be listed in addition to the code that is used for the primary procedure.

    Payment for Category III codes. Medicare payment is not assigned for Category III codes, so coverage and payment must be determined by each Medicare Adminstrative Contractor. You should have Medicare Part B patients sign an Advance Beneficiary Notice (ABN) and append modifier –GA to Category III codes, signifying that the patient acknowledges that he or she may be responsible for payment.

    New HCPCS J Code for CXL

    Also effective Jan. 1 is a new HCPCS J code:

    ● J2787 Riboflavin phosphate ophthalmic solution up to 3 mL. This is more widely known as Photrexa, and is used for corneal cross-linking.

    Tip: Many treatments use 6 mL; in such cases, submit 2 in the unit field with a notation of any residual medication wasted.