Medicare recently changed the conditions for which it finds ocular photodynamic therapy (OPT) “reasonable and necessary.” Double-check your knowledge and make sure you’re on top of what Medicare will--and won’t--pay for.
Background: OPT is a noninvasive treatment for age-related macular degeneration (AMD) that relies on the ability of a photoactive drug to destroy the degenerated cells targeted by the laser. Before 2004, Medicare only approved OPT with verteporfin to treat neovascular AMD--362.52 (Exudative senile macular degeneration)--with predominantly classic subfoveal choroidal neovascularization (CNV) lesions.
Change: Now, Medicare allows for OPT with verteporfin to treat subfoveal occult (hidden) CNV and subfoveal minimally classic CNV associated with AMD (in which the area of classic CNV covers less than 50 percent of the lesion). You have to show Medicare that OPT treatment is medically necessary and thorough documentation will help you do so. The Centers for Medicare & Medicaid Services considers treatments for these two conditions reasonable and necessary under the following circumstances:
• The lesions are small (four disk areas or less in size) at the time of initial treatment or within the three months prior to initial treatment; and
• The lesions have shown evidence of progression within the three months prior to initial treatment.
To provide “evidence of progression,” your documentation must include one of the following:
• Deterioration of visual acuity (at least five letters on a standard eye examination chart)
• Lesion growth (an increase in at least one disk area)
• Appearance of blood associated with the lesion. Note: If AMD doesn’t cause CNV at all, Medicare will leave it up to local carriers to decide if they’ll cover OPT for neovascularization caused by other diseases.
Example: If a patient’s CNV is caused by ocular histoplasmosis (115.02, Infection by Histoplasma capsulatum; retinis) or pathologic myopia (360.21, Degenerative disorders of globe…), report 362.16 (Retinal neovascularization NOS). Depending on your local carrier’s preferences, you may also need to report 115.02 or 360.21 in addition to 362.16.