Retina: The Past Year and the One to Come
By Riva Lee Asbell

As we close out 2012, let's look at some issues that will affect you in 2013.

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Audits

• Verteporfin. Audits of ophthalmic photodynamic therapy (OPT) concentrating on the verification of performance of a fluorescein angiogram within 30 days of the treatment were the focus of a Recovery Auditor audit (RAC). Despite assurances from CMS that the RAC auditor (CGI Federal) has been instructed to discontinue these audits, they did continue for a while. A revision of the National Coverage Determination is allegedly forthcoming as well. You should appeal these requests for refunding the supply payment.
• Modifier 25 + Intravitreal Injections. Expect these audits to continue. The Office of the Inspector General (OIG) has been successful in its pursuit of these audits as witnessed in the Fletcher Allen audit (https://oig.hhs.gov/oas/reports/
  region1/11100515.asp).
• OIG continuing its focus on EMR records. The OIG is continuing its focus on investigating EMR systems with "cookie cutter documentation." When your chart documentation is constantly repetitive for the same patient or the same for all patients it sends up an alert. It is important to individualize your records.

New Technologies and Drugs

• Ocriplasmin. Ocriplasmin (Jetrea, Thrombogenics) has been approved for use via intravitreal injection. As with all new drugs, do not presume that payment for the drug is covered by your Medicare Administrative Contractor (MAC), even if it has received an HCPCS code, until your MAC notifies you and issues billing instructions. The communication usually is by email alert. It behooves all physicians to subscribe to these email alerts, since you are responsible for adhering to these regulations.
• Diabetic Macular Edema. Most MACs have approved, or are in the process of approving, the diagnosis of diabetic macular edema as a covered diagnosis for intravitreal injections of ranibizumab (Lucentis, Genentech).

Diagnostic Tests
Ophthalmology is fairly unique because so many diagnostic tests are performed within the practice.

• Multiple Procedure Payment Reduction (MPPR). For Medicare, most diagnostic tests have a professional and technical component. The professional component is essentially the Interpretation & Report. The technical component is that portion of the fee paid to the entity that is responsible for the ownership, upkeep and supervision of the equipment and personnel. Under ordinary circumstances, the practice is paid a global fee that is a combination of both portions.
  
  Beginning Jan. 1, 2013, when more than one diagnostic test is performed on the same day by any member of a practice, the technical portion will be reduced by 20% for all tests performed subsequent to the first one.

• Orders for Diagnostic Tests. Many providers fail to place an order for a diagnostic test in the chart. This is especially prevalent in EMR systems. Medicare has given notice that if providers are not properly enrolled, diagnostic tests will be denied for payment by CMS.

Surgery
Changes affecting retina surgical coding include the elimination of CPT code 65805 (paracentesis of anterior chamber of eye with diagnostic aspiration of aqueous) and the revision of CPT code 65800 (paracentesis of anterior chamber of eye, separate procedure; with removal of aqueous). This essentially has removed the differential between paracentesis for diagnostic and therapeutic purposes. Note that most of the vitrectomy codes are bundled, so always check before submitting claims.