Q:What's the status of Medicare reimbursement for intravitreal injections for retinal disease?

A:The past five years have seen a dramatic increase in claim submissions for CPT code 67028, intravitreal injection of a pharmacological agent, separate procedure. Medicare claim volume grew 192 percent from 2002 to 2003. Injections of triamcinolone (Kenalog) account for most of this increase, but other substances are in use or being studied to treat conditions including wet AMD, CSME, CRVO, retinal detachment, endophthalmitis, fungal infections, vitreous hemorrhage and CMV retinitis.

Two CPT codes describe these injections: CPT 67025 Injection of vitreous substitute, pars plana or limbal approach, fluid-gas exchange, with or without aspiration, separate procedure; and CPT 67028 Intravitreal injection of a pharmacologic agent, separate procedure. They are distinguished by the injected substance: vitreous substitute or pharmacologic agent; 67025 is a major surgery with a 90-day postop period; 67028 is a minor procedure with zero postop days.

To determine specific coding and reimbursement considerations, you need to answer many questions: What is the medical indication? Is the substance FDA-approved? Is this an off-label use? Is it considered investigational or experimental? Was the injected substance a pharmaceutical or a vitreous substitute? Is the procedure being performed concurrently with another surgical procedure? Is there a history of a prior surgical procedure? Is this being performed as part of postoperative care? Is this procedure performed in the office, ASC or hospital outpatient department?

Coverage varies and is unpredictable. To be safe, obtain pre-certification or pre-authorization from the third-party payer. Alternately, ask the patient to assume financial responsibility should reimbursement be denied. Use an Advance Beneficiary Notice for Medicare patients, or a financial waiver for non-Medicare patients, to document the patient's acceptance.

Q:What is the implication of "separate procedure" status in the code's definition?

A:Some items listed in the CPT manual are commonly carried out as an integral component of a total service or procedure and are identified by the inclusion of the term, "separate procedure." These codes should not be reported in addition to the code for the total procedure or service of which they are an integral component. When such a separate procedure is carried out independently or considered unrelated or distinct from other procedures/services provided at that time, however, it may be reported by itself or in addition to other procedures.

An intravitreal injection may be an incidental component of another procedure, such as CPT 67108, Repair of retinal detachment. As an integral component, it is not separately reimbursed. If the injection is a stand-alone procedure, file a separate claim.

Q:May this procedure be reimbursed during the postop period of another surgery?

A:Sometimes. The Medicare global surgery package includes any additional medical or surgical services during the postop period to treat a complication that doesn't require a return to the operating room (MCPM Ch.12, §40.1A). So, unplanned injections performed in-office to cope with complications are not separately reimbursed. If the injection is given in an OR, however, it may be reimbursed (using modifier -78). Pre-planned intravitreal injections are not part of the global surgery package and are reimbursed under the rules for staged procedures (using modifier -58). Other payers may have different coverage guidelines.

Q:If paracentesis is performed immediately prior to an intravitreal injection, is it reimbursed separately?

A:No. Some ophthalmologists remove aqueous humor from the anterior chamber prior to the intravitreal injection. Paracentesis (CPT 65800 or 65805) is performed as a prophylactic measure to avoid elevating intraocular pressure. Since both of these CPT codes carry the separate procedure designation, and there is no separate reason for paracentesis, do not file an additional claim.

Q:Does the place of service affect reimbursement?

A:CPT 67025 is eligible for Medicare reimbursement of a facility fee under Group 1 of the fee schedule. CPT 67028 is ineligible for a facility fee. Since the beneficiary can't be charged a facility fee for a covered service, the ASC should seek compensation from the surgeon. One suggestion for a fair amount is the difference between the non-facility and facility reimbursement for the surgeon ($47 in 2005). The 2005 fee schedule lists the surgeon's reimbursement as follows:
 • 67025 performed in the office, $621.14; in ASC or HOPD, $507.45
 • 67028 performed in the office or ASC, $202.37; in HOPD, $155.38

Reimbursement for vitreous substitute is included in the facility reimbursement for the ASC and HOPD, as is reimbursement for pharmacologic agents in the HOPD facility fee. However, in an office setting or ASC, injected pharmacologic agents are separately reported on a claim using HCPCS J-codes.

Mr. Corcoran is president of Corcoran Consulting Group, corcoranccg.com. Contact him at kcorcoran@corcoranccg.com or 1 (800) 399-6565.