AN ANALYSIS OF CMS RETINA
`UTILIZATION STATISTICS
`
`Recent changes in reimbursement will likely lead to changes in utilization.
`
`BY RIVA LEE ASBELL
`
`The Medicare Part B National Summary
`Data File (previously known as BESS files)
`is a downloadable public file that provides
`detailed breakdowns of volume of physician
`services delivered co Medicare beneficiaries,
`and payments for those services, by individual
`procedure code. Entries in this file are limited
`co Medicare fee-for-service Part B Physician/
`Supplier data Beneficiaries in the Medicare Advantage (man(cid:173)
`aged care) portion of the program are not included
`Statistics in the currently available BESS files are based on
`calendar year 2014, the last year that these statistics were
`compiled.1 In Table 1, I have ranked the cop 10 retina proce(cid:173)
`dures in the BESS files in order of highest utilization (allowed
`services) and then by the amount of dollars allowed (allowed
`charges) by Medicare for those same procedures.
`Allowed services are those that Medicare deems valid
`for payment. The Medicare Physician Fee Schedule data(cid:173)
`base lists the total dollar amount allowed for each service.
`Medicare pays 80% of the allowed amount fee-for-service,
`and the remaining 20% is paid by either supplementary
`insurance or the patient.
`This year began with some alarming reimbursement cues, and
`this article discusses coping with some of the problems that
`have emerged and offers a peek into future potential audits.
`
`SURGERY
`Below are allowed services for selected retina procedures,
`along with their Current Procedural Terminology (CPT)
`codes and discussion of relevant issues, recent changes, and
`the effects of these changes. Note that the rankings used in
`Table 1 precede each description.
`
`External Laser Procedures
`No. 2: Destruction of localized lesion of retina; photoco(cid:173)
`agulation (CPT code 67210,jocal laser)
`No. 3: Treatment of extensive or progressive retinopathy
`with photocoagulation (CPT code 67228, panretinal photo(cid:173)
`coagulation {PRPJ)
`No. 5: Pro phyla.xis of retinal detachment (RD) without
`drainage; photocoagulation (CPT code 67145)
`
`The global period for PRP was changed from 90 days co
`10 days, thus classifying it as a minor procedure rather
`than a major procedure. When a procedure is classified
`as major, an office visit can be billed within 24 hours of
`making the initial decision for surgery by using modi-
`fier 57. For procedures now considered minor, with a
`global period of O or 10 days, the office visit is packaged
`with the procedure, and caution is warranted when using
`modifier 25.2 Modifier 25 is rarely warranted for a second
`or third treatment of PRP and is only appropriate for a first
`treatment specifically if another significant, separate condi(cid:173)
`tion is being evaluated. With the global period rule changes
`for 2016, you may find your utilization of PRP increasing. If
`this is the case, make sure your rationale for the additional
`procedures is clearly documented in the chart.
`The National Correct Coding Initiative (NCO) lists
`sets of codes known as code pairs that cannot be used
`together. Do not allow your billers and coders to break
`the NCCI bundles except in unusual, well-documented
`circumstances.
`The BESS statistics reveal a surprisingly high number of
`focal lasers considering that the procedure is bundled
`with all vitrectomy surgery codes. See the bullet above.
`A common use of external focal laser is for treatment of
`diabetic macular edema. lntravitreal injections of various
`drugs are becoming more popular options for treatment.
`Utilization of the laser modality will probably decrease.
`
`Vitrectomy Codes
`No. 4: Pars plana vitrectomy (PPV) with macular hole repair
`(CPT code 67042)
`No. 7: PPV with epiretinal membrane (ERM) peeling
`(CPT code 67041)
`One of the unexpected reimbursement decreases for
`2016 resulted in macular hole repair and ERM peeling
`having the same level of reimbursement. In previous
`years, 67042 paid more than 67041. Many retina cases
`involve both procedures; however, the procedures are
`bundled so only one should be selected for coding pur(cid:173)
`poses. Both should be documented. It is advisable to
`use the code most important to the procedure(s) being
`
`22 RETINA TODAY I M AY/ JU NE 2016
`
`Novartis Exhibit 2309.001
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`TABLE 1. CMS 2014 BESS STATISTICS FOR SELECTED RETINA PROCEDURES
`No.of
`Rank for
`Rank for CPTCode/
`Amount of
`Author's Comments
`Allowed Descriptor
`Allowed
`Total Allowed
`(Allowed services includes all POS)
`Allowed
`Services
`Services
`Charges
`Charges
`1
`1
`$211563175
`
`2625485
`
`67028 / lntravitreal
`injection of a
`pharmaco logic
`agent
`67210 / Destruction 84454
`of localized
`lesion of retina;
`photocoagulation
`67228 / Treatment of 82027
`extensive progressive
`retinopathy;
`photocoagulation
`67042 I PPV with
`removal of ILM
`
`4
`
`2
`
`3
`
`10
`
`8
`
`6
`
`$43940908
`
`$81827901
`
`$61161 616
`
`$12723748
`
`$25847097
`
`$30963885
`
`41081
`
`67145 /
`Prophylaxis of RD;
`photocoagulation
`
`24428
`
`67036 / PPV
`
`23659
`
`67041 / PPV with
`removal of precellular
`membrane
`
`22718
`
`• Correlates with high utilization (No. 1) for OCT
`(92134)
`• In general, do not code with office visit using
`modifier 25
`• If using intravitreal injections for DME, make sure
`utilization is decreased
`, Still has 90-day global period; do not bill additional
`sessions
`• 2016 CPT changes will result in more utilization
`• Do not code office visits with subsequent sessions
`for original problem
`
`• Reflects older coding when repair of macular hole
`paid more than ERM peeling
`• Retains 90-day global period; do not bill additional
`sessions
`
`• Do not use for removal of silicone oil; use 67121
`(removal of implants material, posterior segment)
`• Mandatory co use with 67108 for complex RD
`repair
`• Peeling of the hyaloid membrane does not usually
`count for chis code
`• If performed with cataract extraction and IOL,
`may need co break NCCI bundle with modifier 59
`• Make sure peeling of ERM is clearly documented
`in coding complex RD repair
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`5
`
`7
`
`9
`
`17464
`
`16273
`
`$33116 038
`
`$277%444
`
`$22621490
`
`67108 / Repair of RD 21723
`with vicrectomy, etc.
`67113 / Repair of
`complex RD with
`vitreccomy and
`membrane peeling
`67040 I PPV with
`• Always check NCCI bundles; it is frequently
`endolaser PRP
`bundled with ocher surgical procedures
`Abbreviations: CPT, Current Procedural Terminology; DME, diabetic macular edema; ERM, epirecinal membrane; ILM, internal
`limiting membrane; IOL, intraocular lens; NCCI, National Correct Coding Initiative; OCT, optical coherence tomography; PPV, pars
`plana vicreccomy; RD, retinal detachment; POS, places of service
`
`performed; however, there are times when PPV with
`ERM (67041) must be the procedure code of choice. This
`is imperative when coding for complex RD repair (CPT
`code 67113), which mandates that both a retinal detach(cid:173)
`ment and ERM peeling be performed.
`
`No. 6: PPV (CPT code 67036)
`No. 10: PPV with endolaser PRP (CPT code 67040)
`NCCI bundles frequently appear when multiple CPT
`codes are used in complex cases. The same caveat
`applies regarding not unbundling NCCI code pairs.
`Unbundling is accomplished by using modifier 59.
`This usage has been heavily audited and continues to
`
`garner attention from the US Department of Health
`and Human Services Office of Inspector General and the
`Centers for Medicare and Medicaid Services (CMS).
`Example: A trauma case involved a corneoscleral lac(cid:173)
`eration with a magnetic foreign body that was removed
`by nonmagnetic extraction. A PPV and lensectomy for
`traumatic cataract were performed. The following codes
`would be used: 65265 (nonmagnetic foreign body extrac(cid:173)
`tion); 65280 (repair of corneal-scleral laceration); and
`66850 (lensectomy). The PPV (67036) is bundled with the
`foreign body extraction (65280) and it is the lower-paying
`code of this code pair edit and thus should not be coded.
`Full coding for this case will be described in the next issue.
`
`M AY/ JUNE 2016 I RETINA TODAY 23
`
`Novartis Exhibit 2309.002
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`Repair of Retinal Detachment
`No. 8: Repair of RD by vitrectomy, any method, includ(cid:173)
`ing, when performed, air or gas tamponade,jocal endolaser
`photocoagulation, cryotherapy, drainage of subretinal fluid,
`scleral buckling, and/or removal of lens by same technique
`(CPT code 67108)
`No. 9: Repair of complex RD with vitrectomy and membrane
`peeling, etc. (CPT code 67113)
`Large curs in reimbursement occurred for these codes in 2016.
`In order to use complex RD repair code, you must also
`perform membrane peeling. No matter how complicated
`the case, without the ERM peeling. it cannot be coded as
`complex.
`
`Special Case: lntravitreal Injections
`No. 1: lntravitreal injection of pharmacological agent (CPT
`code 67028)
`lntravitreal injections rank first both in the number of
`allowed charges and as the most highly utilized procedure
`in ophthalmology, and that definitively puts them on
`CMS's radar for audits.
`Practices should not routinely engender unwarranted pay(cid:173)
`ment for the office visit by using modifier 25 without a
`significantly separate clinical problem being addressed at
`the same time as the intravitreal injection.2
`Be cautious regarding the level of office visit when one is
`billed. There should be medical necessity for any of the
`elements performed, and they should not be performed
`solely to "count the bullets."
`
`DIAGNOSTIC TESTS
`Table 2 presents the top five ophthalmic diagnostic tests
`used in retina practices. With the high total payments and uti(cid:173)
`lization statistics for some of these services, comments on chart
`documentation and audit prevention are warranted
`For chart documentation it is important to keep in
`mind that there has to be an order for each diagnostic test
`except extended ophthalmoscopy and gonioscopy, both
`of which are considered physician services. Additionally,
`with the exception of gonioscopy, each test requires an
`Interpretation and Report (l&R).
`Avoid unbundling NCCI code pair edits. The most frequent
`code pairs that practices want to unbundle are fundus photos
`with optical coherence tomography (OCT) and extended oph(cid:173)
`thalmoscopy with office visits in the global period including the
`day of intravitreal injections.
`
`Extended Opht halmoscopy (CPT codes 92225 and 92226)3
`The l&R does not have to be a lengthy report, but it should
`be separately identifiable in the chart documentation. The l&R
`may duplicate information in other areas of the chart note for
`that day, such as in the Assessment and Plan, and it must con(cid:173)
`tain a diagnosis; comparative data, when applicable; and clinical
`
`management of the patient as a result of this information.
`With most practices now using electronic health records
`(EHRs), the mandatory drawing becomes problematic in that
`the software of most EHRs does not permit making a drawing
`that meets Medicare guidelines. Each Medicare Administrative
`Contractor (MAC) may issue its own Local Coverage
`Determination (LCD) with requirements for the drawing. and
`each provider is beholden to follow these determinations. If your
`MAC does not have an LCD use the one at NGSMedicare.com.
`Extended ophthalmoscopy continues to be a heavily audited
`service, and voluntary refunds resulting from internal or external
`audits are quite common. Medical necessity must be present
`for each eye because it is a unilateral service. Furthermore, the
`NCCI bundles should be adhered to. Medicare generally does
`not pay for extended ophthalmoscopy in the global period of a
`major or minor surgery. There is some confusion when it is per(cid:173)
`formed with intravitreal injections and other procedures with
`a global period of O days. For the day of service, the extended
`ophthalmoscopy and other NCCI edits do apply.
`
`Fundus Photography (CPT code 92250) and OCT
`(CPT code 92134)
`Fundus photography always must have its own l&R, even
`when performed with fluorescein angiography (FA). FA is
`a unilateral test, meaning there must be medical necessity
`for each side, and each side must be addressed. Fundus
`photography, on the other hand, is a bilateral test, so the
`fee encompasses testing of both eyes. If only one eye is
`tested, then modifier 52 should be applied.
`Fundus photography and OCT are bundled. There has
`been significant application of modifier 59 to break the NCCI
`bundles. Unless there is a separate medical reason for break-
`ing the bundle, the practice is best avoided. Much of this was
`prompted by the payment differential between the two codes;
`for 2016, the national average payment for fundus photography
`is $78.82 and for OCT is $45.50.
`More important, in terms of medical necessity, the diagnostic
`test that is the standard of care for medical decision-making in
`wet macular degeneration treated with intravitreal injections is
`OCT, not fundus photography.4 All related clinical studies are
`designed around OCT results.
`
`TAKE-HOME POINTS
`Make sure the rationale for billing additional sessions for
`PRP (67228) are well documented now that the global
`period has been reduced to 10 days. Increased utilization
`invites increased scrutiny.
`The coding of complex retinal detachment repair man(cid:173)
`dates both repair of retinal detachment with vitreccomy
`and peeling of ERM.
`Office visits are packaged with all minor procedures (0- or
`10-day global period). If you do not have a separate, signifi(cid:173)
`cant clinical problem that is being addressed, do not use
`
`2 4 RETINA TODAY I M AY/ JU NE 2016
`
`Novartis Exhibit 2309.003
`Regeneron v. Novartis, IPR2021-00816
`
`

`

`TABLE 2. CMS 2014 BESS STATISTICS FOR SELECTED RETINA DIAGNOSTIC TESTS
`Rank for
`No. of Allowed Rank for Amount of
`CPT Code/
`Author's Comments
`Allowed
`Allowed Total Allowed (Allowed services includes all POS)
`Descriptor
`Services
`Services
`(All POS)
`Charges Charges
`
`1
`
`2
`
`3
`
`4
`
`5
`
`92134 / Scanning
`computerized
`ophthalmic
`diagnostic imaging,
`posterior segment,
`with l&R, unilateral
`or bilateral; retina
`
`92225 /
`Ophthalmoscopy,
`extended, with
`retinal drawing with
`l&R; initial
`
`92226 /
`Ophthalmoscopy,
`extended, with
`retinal drawing with
`l&R; subsequent
`
`5401832
`
`1
`
`$243598345
`
`• Do not unbundle the NCCI code pair edits
`between 92134 and 92250. The test that is medically
`necessary for intravitreal injection treatment for the
`diagnosis of wet macular degeneration is OCT
`
`883934
`
`5
`
`$28450902
`
`• NCCI bundles in place when performed the same
`day as surgical procedures and in global period
`when related
`
`2234441
`
`3
`
`$67419209
`
`• see above
`• Make sure LCDs are adhered co for drawings and
`medical necessity. EHR sketches are usually not in
`compliance
`
`92235 / FA with
`l&R
`
`1104945
`
`92250 / Fundus
`photography with
`l&R
`
`2907318
`
`4
`
`2
`
`$126027741
`
`$219994673
`
`• Unilateral test: must have medical necessity for
`each side
`• l&R muse address each side
`
`• Do not unbundle with NCCI
`• Do not bill in place of OCT
`• Document medical necessity and different
`diagnosis if billed with OCT
`
`Abbreviations: CPT, Current Procedural Terminology; DME, diabetic macular edema; EHR, electronic health records; l&R,
`interpretation and report; LCDs, Local Coverage Determinations; NCCI, National Correct Coding Initiative; POS, places of service;
`OCT, optical coherence tomography; FA, fluorescein angiography
`
`modifier 25 to engender payment for the office visit.
`Caution is advised in selecting the proper level code
`when using modifier 25 because there may not be
`medical necessity for some of the elements.
`Avoid breaking NCCI bundles by using modifier 59, espe(cid:173)
`cially bundles involving OCT and fundus photography
`and those involving extended ophthalmoscopy when
`performed on the day of a procedure.
`
`CONCLUSIONS
`Our peek into the future based on the analysis of statistics
`from the BESS files shows the likelihood that, for the near
`future, intravitreal injections will remain the No. 1 surgical
`service. Be over-compulsive and obsessive with your chart
`documentation and do not be reckless with your use of
`modifier 25 to engender payment for a same-day office visit;
`this will serve you in good stead for audits. The utilization for
`repair of macular hole and removal of ERM will likely come
`closer together because the payments for each are the same.
`
`Additionally, utilization of PRP will most certainly increase.
`For billing and coding of diagnostic tests, make every effort
`to follow the instructions for the l&R. This is the crux of diag(cid:173)
`nostic testing reimbursemenr, and it is where audits will trap
`you. Although there is usually sufficient evidence to prove that
`the test itself was performed, it is the l&R, which is considered
`the physician's work, that is o~en missing or incomplete. ■
`
`1. Ctnrers for MediGlre &MedGli:I Seivices. Pan BNatioralSumma,y Data file(Preliou~ykno~n as BESS). w1ow.crrr,grN/
`Researdl-Statistics-Oata .. nd-S)Ste~~nloadatje-P\rbli:-Ust-fi~s/Pan-B-Natioral-Summary-Oata-file/Oieiview. html.
`October 11, 1015. Accessed April lB, 1016.
`2 Asbell fl. Same-<lay dlice 1isits and 9.rrge,y: getting p:,i:I. RetJiJo Today.101 S; 10(7) :25-28.
`l. Asbellll. PenlsofEHR:el!ended ophthalmiscol1)'.Rtli11<1 Today.1015;1(X6):18-10.
`4. Asbellll. Chan doormentation for ophthalmic diillJlostictests. &ri11<1 Today.1014;9{4):19-JO.
`
`Riva Lee Asbell
`■ principal, Riva Lee Asbell Associates, in Fore Lauderdale, Fla.
`■ financial interest: none acknowledged
`■ rivalee@rivaleeasbell.com
`■ CPT codes copyright 2015 American Medical Association
`
`M A Y/JUNE 2016 I RETINA TODAY 2S
`
`Novartis Exhibit 2309.004
`Regeneron v. Novartis, IPR2021-00816
`
`