JAN 15, 2019
Fact Sheet for Coding Corneal Collagen Cross-Linking
As of Jan. 9, 2019
What it Is
Corneal collagen cross-linking (CXL) is a surgical technique used to stop the progression of corneal ectasia — the most common of which is keratoconus — after refractive surgery.
What You Need to Know About Insurance Coverage for CXL
Over the past year, insurance coverage for CXL has increased. Even payers without a published policy may approve the procedure on a case-by-case basis.
Check the unique payer website often for coverage policy. To reduce denials, always preauthorize the procedure and the drug.
Note: Many coverage policies require documented progression of keratoconus. Often, chart notes are required for preauthorization or before processing the claim.
Reasons to Verify Your Coverage Before Performing CXL
The existence of a CPT code and a specific medication code does not ensure coverage or payment amount. You must verify coverage before performing each procedure with each payer.
- 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 even if you suspect the insurance payment may not cover the cost of both the procedure and drug. This would most likely violate your contract.
- Negative coverage policy: Negative coverage policies or lack of insurance coverage must be disclosed to the patient. A discussion should follow with the patient to determine if the patient wishes to self-pay.
- No published policy: Contact the carrier. You cannot assume noncoverage. If you collect from a patient and the patient submits the claim and obtains coverage, you will likely have to refund the fees you have collected. The insurance reimbursement may be lower than expected and appeals after the claim has been underpaid require a great deal of work. You should contact the carrier before performing the procedure.
How to Code CXL Correctly Starting Jan. 1, 2019
- Submitting a clean claim increases the likelihood of obtaining appropriate reimbursement.
- Category III code 0402T Collagen cross-linking of cornea (including removal or the corneal epithelium and intraoperative pachymetry when performed) and
- HCPCS code J2787 Riboflavin 5’- Phosphate, ophthalmic solution, up to 3 ml
- Since the procedure requires the use of 6 ml of solution, submit 2 units.
- The NDC number and description for the Photrexa cross-linking kit remain:
- NDC 25357-025-03 Photrexa cross-linking kit
- For payers that require an 11-digit NDC:
- Add a zero to the NDC: 25357-0025-03.
- The amount reimbursed for the medication will vary between payers.
- Each vial is one unit.
- If the second vial was partially used, it is less than 1 unit, so it would not be reported by modifier –JW. Just document in the medical record that residual medication, less than 1 unit, is wasted.
- If one of the two vials is wasted, submit
- J2787 1 unit
- J2787-JW 1 unit
- Note: Claims for dates of service through Dec. 31, 2018 should still be submitted with HCPCS J3490 Unspecified medication.
Since Food and Drug Administration approval of CXL in April 2016, the service has been billed with a Category III code 0402T Collagen cross-linking of cornea (including removal or the corneal epithelium and intraoperative pachymetry when performed) and an unspecified HCPCS code J3490 Unspecified medication.
New technology codes and unspecified codes pose specific challenges to reimbursement. New technology codes, even when covered, have no Relative Value Units (RVUs) assigned to them and therefore often lack a set fee schedule amount. Unspecified J codes cause numerous claim submission formatting challenges. Many claims have been denied or rejected for invalid CPT and/or HCPCS or NDC codes