Accurate coding is essential for retina practices performing intravitreal injections, especially when handling retina injection coding. While medication and modifier updates occur frequently, understanding these basics ensures proper reimbursement:
- CPT® Code Consistency: CPT® code 67028 remains constant for administering the medication.
- HCPCS Level II Code Tracking: Codes for injected drugs (HCPCS Level II) vary and require ongoing monitoring.
- Modifier Usage:
- Unilateral injections: Use LT (Left) or RT (Right) modifier.
- Bilateral injections on the same day: Use modifier 50 (Bilateral procedure) with one billing unit. The modifier clarifies treatment on both eyes for accurate reimbursement (150% of allowed amount).
Next Steps: We’ll explore additional billing details like J code complexities and patient affordability programs in the following sections.
Discover expert tips and guidelines for precise retina injection coding to optimize billing accuracy and streamline reimbursement processes.
Understanding J Codes and Dilated Exam Billing:
- J Code Challenges: HCPCS Level II codes (J codes) for injected medications are a constant source of complexity. These codes change frequently, especially for new drugs.
- Example: Faricimab-svoa (Vabysmo) initially lacked a permanent J code. Practices used a temporary code (J3590) until a permanent one (J2777) was assigned in October 2022. This highlights the importance of staying updated on J code changes.
- Prior Authorization: Many payers require prior authorization for specific J codes. Obtaining authorization for a temporary code might not carry over to the permanent code, leading to denied claims.
- Dilated Exam Billing:
- If the dilated exam solely confirms the need for an injection performed the same day, it’s not separately billable.
- However, if the exam is for a separate diagnosis in the other eye on the same day as a unilateral injection, bill an evaluation and management (E/M) code with modifier 25 (significant, separately identifiable E/M service).
Next Steps: We’ll delve deeper into billing units for J codes and explore programs that help patients afford these medications.
Billing Units and Prior Authorization:
- Units per J Code: The number of units billed for each J code varies.
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- Unclassified codes (e.g., J3590) typically use one unit.
- Established medications (e.g., Avastin) might have different J codes depending on the payer (J9035 or J7999), but usually use one unit.
- Newer medications (e.g., Eylea HD, Vabysmo) have specific J codes with designated unit amounts (Eylea HD – 8 units, Vabysmo – 60 units).
- Prior Authorization Strategy: When seeking prior authorization for a J code, request enough units to cover each injection during treatment. This ensures proper coverage and avoids issues where authorization for a lower unit amount (e.g., 2 units for bilateral Vabysmo) doesn’t match your actual billing (120 units).
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Modifier JZ for Zero Waste:
- Medicare requires modifier JZ for single-dose vials with no wasted medication since July 2023. This complements existing modifier JW for wasted medication.
- While initially unclear, JZ can be used with J7999 for compounded drugs like Avastin.
- Commercial payers may not immediately adopt JZ, but its use hasn’t resulted in claim denials in our experience.
Next: We’ll discuss ways to help patients manage the high cost of these medications through various assistance programs.
Boost Reimbursements & Efficiency: Allzone’s Medical Coding Solutions:
Allzone offers medical coding services that are designed to help healthcare providers maximize their reimbursements and efficiency.
Here’s a breakdown of our services:
Medical Coding: Allzone has a team of certified and experienced medical coders who can assign the correct Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, and International Classification of Diseases, Tenth Revision (ICD-10) codes to your medical records. Accurate coding is essential for ensuring that insurance companies reimburse you correctly for the services you provide.
Superbill and Medical Record Coding: Allzone can create superbills, which are itemized lists of all services provided to a patient during a visit. The superbill also includes information about the patient’s insurance, diagnosis codes, and other relevant details. Accurate superbills are essential for submitting clean claims to insurance companies.
Revenue Cycle Management (RCM): Allzone’s RCM services encompass the entire revenue cycle, from patient scheduling and insurance verification to claim submission and denial management. By outsourcing your RCM to Allzone, you can free up your staff to focus on patient care.
Overall, Allzone’s Medical Coding Reimbursement Services can help you improve your coding accuracy, streamline your billing process, and maximize your reimbursements.