Intravitreal Medications for Geographic Atrophy – Retinal Physician

Billing questions will arise with new drug treatment. According to the American Academy of Ophthalmology EyeWiki, “Geographic atrophy is a chronic progressive degeneration of the macula, as part of late-stage age-related macular degeneration (AMD). The disease is characterized by localized sharply demarcated atrophy of outer retinal tissue, retinal pigment epithelium and choriocapillaris. It starts typically…

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Medicare payments for eye exam coding – Ophthalmic Professional

Why you might choose differently this year In my last column, I briefly reviewed how Evaluation and Management (E/M) exam coding for 2021 had changed as of Jan. 1 . Remember, history and exam elements (other than the reason for presentation, chief complaint) are no longer a relevant consideration for the level of E/M exam…

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Tepezza™ Approval

Tepezza™ (teprotumumab-trbw) by Horizon Therapeutics was approved by the FDA on January 21, 2020. This is the first FDA-approved drug treatment for thyroid eye disease. The FDA granted this drug priority review, fast track, breakthrough therapy, and orphan drug designation. It is an exciting development for those managing and treating thyroid eye disease patients –…

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Global Confusion – Retinal Physician

Billing for a procedure done during the global period of a prior procedure. Physicians and billers are often confused regarding which modifiers to use when a procedure is performed in the global period of a prior procedure. Here’s my attempt to provide some clarity. This article addresses the following questions: What modifiers apply when a…

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When Extended Ophthalmoscopy and Imaging Collide – Retinal Physician

Distinction must be made between additive and duplicative information. Extended ophthalmoscopy (EO; CPT 92225, 92226) and imaging of the retina (CPT 92250, 92134, 92235, 92240) are overlapping services. This overlap often leads to biller confusion as to whether both may be reimbursed when performed concurrently. When EO and imaging are performed concurrently, reimbursement depends on…

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New therapy = new code – Ophthalmology Management

New therapies always engender questions about reimbursement — and often, new codes. Dexamethasone ophthalmic insert falls into this category. This article addresses the following questions: What is dexamethasone ophthalmic insert? How is the procedure coded? How is the supply coded? Is it covered? Do HOPDs or ASCs get a facility payment? What about the surgeon’s…

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The reimbursement angle on aniridia – Ophthalmology Management

Aniridia is a rare condition defined as the full or partial absence of the iris. Most often it occurs as a result of a traumatic injury; less often, it is a congenital abnormality. The patient is severely handicapped due to photophobia from too much light. There is a lengthy history of treatments for aniridia, notably…

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Audits Increase as Injections Increase – Retinal Physician

Prepare for the inevitable with proper documentation. Injectable drugs for retinal disease — particularly ranibizumab (Lucentis; Genentech) and aflibercept (Eylea; Regeneron) — are the focus of audits for Medicare and other payers. How can you avoid problems? This article addresses the following questions: Why does Medicare devote so much attention to anti-VEGF drugs? What documentation…

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CMS rules and family ties – Ophthalmology Management

We all know that Medicare prohibits charging for services to immediate family members, but the big, recurring question that we receive is: what does this really entail? This article addresses the following questions: Why doesn’t Medicare allow claims for services to family members? What are the excluded relationships? How does Medicare define “immediate relative”? Who…

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