Article

Coding & Reimbursement

Floater treatment goes beyond the retina specialist

YAG laser treatment for vitreous floaters has gained in popularity, especially with the advent of new lasers that can focus on-axis while simultaneously allowing greater depth of treatment and improved spatial reference. This allows lower energy, minimizing the risk of damage to the natural lens or the retina. Once the province of retinal specialists only, the procedure is attracting the attention of other ophthalmologists.

Q. Why treat vitreous floaters with laser?

A. Vitreous floaters are very common, and the intensity of the associated symptoms varies widely; most need no treatment,1,2 although they sometimes have a negative impact on health-related quality of life. Surgeons have used YAG laser to treat vitreous floaters since the 1980s, often with good, although not universal, success.3,4 Alternately, pars plana vitrectomy (PPV) may be used to treat clinically significant vitreous floaters, although PPV is more invasive than YAG laser.5

Patient complaints, symptoms and problems with activities of daily living guide the decision for surgery. For example, patients complaining of significant difficulty performing daily tasks, such as driving, operating heavy equipment and other activities requiring clear, sharp vision, may merit laser floater treatment if there are no contraindications. Patients with occasional, annoying symptoms but without moderate to severe disability are not good candidates for laser floater treatment. Patients with significant floaters that cannot be treated safely with laser due to high risk of complications should be considered for PPV.

Q. Is the procedure covered by Medicare and other payers?

A. Usually not. At this time, no Medicare local coverage determinations (LCD) exist. Two private payers describe the therapy as “experimental and investigational.”6,7

A claim is supported by a number of factors:

  • The laser is FDA approved and its use is consistent with the manufacturer’s directions for use.
  • An eye exam by the surgeon established the indications for surgery consistent with proper standards of care.
  • The patient has been advised of the risks, benefits and alternatives to surgery and gives informed consent to proceed.
  • The patient is cleared for surgery by the surgeon or other qualified health-care professional.
  • An operative report by the surgeon is in the medical record, identifies the indications for surgery, describes the procedure in detail, includes discharge instructions and is signed by the surgeon.

Q. How is this procedure coded?

A. There are two CPT codes that apply:

  • 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages)
  • 67299 (Unlisted procedure, posterior segment)

Use CPT 67031 when a visually significant opaque floater is severed from its attachment, allowing it to sink to the bottom of the vitreous and out of the line of sight. When severing does not occur, CPT 67031 does not apply. Instead, use CPT 67299 to describe photoablation, destruction or vaporization of a vitreous floater for complete removal.

Q. What are the payment rates?

A. For CPT 67031, the 2018 national Medicare Physician Fee Schedule amounts for CPT 67031 are $399.96 for the surgeon in-office and $365.76 in a facility. Facility fees are $487.98 for a HOPD and $254.19 for an ASC. These amounts are adjusted by local indices, so actual payments vary. As usual, other third-party payers set their own rates that may vary considerably from Medicare.

Like other unlisted codes, 67299 poses administrative challenges:

  • There is no fee schedule for physicians; claims are adjudicated on a case-by-case basis.
  • There is no published global period.
  • Unlisted codes are not eligible for Medicare ASC facility fee reimbursement.
  • Each claim stands alone; reimbursement for one case does not set precedent for the next.

Q. If coverage is unlikely or uncertain, how should we proceed?

A. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.

An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.

For Part C Medicare (Medicare Advantage, or MA), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services. MA Plans have their own waiver processes; using the ABN form is not permitted.

For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.

Q. How frequently is laser vitreolysis performed?

A. Within the Medicare program, CPT 67031 was reimbursed 4,916 times in 2016; CPT 67299 was paid only 408 times. Ophthalmologists who perform this procedure frequently may attract unwanted attention.

When challenged during postpayment review of a rarely performed procedure, careful chart documentation is your best defense. OM

REFERENCES

  1. Webb BF, Webb JR, Schroeder MC, North CS. Prevalence of vitreous floaters in a community sample of smartphone users. Int J Ophthalmol. 2013;6:402-405.
  2. Symptoma – Vitreous Floaters (Eye Floaters). Prevalence is high. Generally not treated. https://www.symptoma.com/en/info/vitreous-floaters . Accessed May 23, 2018.
  3. Aron-Rosa D, Greenspan DA. Neodymium:YAG laser vitreolysis. Int Ophthalmol Clin. 1985 Fall;25:125-134.
  4. Tsai WF, Chen YC, Su CY. Treatment of vitreous floaters with neodymium: YAG laser. Br J Ophthalmol. 1993; 77:485-488.
  5. Delaney YM, Oyinloye A, Benjamin L. Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye. 2002 Jan;16:21-26.
  6. Aetna. YAG laser in ophthalmology and other selected indications. Clinical Policy Bulletin 0354. http://www.aetna.com/cpb/medical/data/300_399/0354.html . Accessed May 23, 2018.
  7. BC/BS of FL. Medical Coverage Guidelines: Laser Vitreolysis. Rev 05/12/14. (search on vitreolysis). http://mcgs.bcbsfl.com . Accessed May 23, 2018.