Reimbursement for Amniotic Tissue

FREQUENTLY ASKED QUESTIONS:

REIMBURSEMENT FOR AMNIOTIC TISSUE

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Q: What is BioDOptix® and how is it used in eye care?

A: BioDOptix® amniotic extracellular matrix is a dehydrated, membrane allograft derived from amniotic tissue for use in ocular tissue repair. This tissue is recovered from pre-screened live healthy donors during cesarean childbirth. BioDOPTIX® comes in 3 different disc and 2 different rectangular sizes and may be trimmed to size in its dehydrated state. BioDOPTIX® has a 5-year shelf life when stored at ambient temperature.

BioDOptix® is used primarily in the treatment of acute and chronic cornea surface wounds and defects. It may be used as a graft to facilitate ocular tissue repair or as a biological dressing to protect the ocular surface. As a graft, it provides a natural substrate that is conducive for migration and attachment of the patient’s own epithelial cells.1 As a biological dressing, it shields the regenerating epithelium from frictional forces during the healing process and protects the underlying stroma if it is inflamed or scared.1 Some common conditions for which amniotic tissues may be used include:

- Chemical burns of the ocular surface
- Corneal epithelial defects such as:
  - Bullous or band keratopathy
  - Epithelial basement membrane dystrophy
  - Recurrent corneal erosions
  - Keratitis (exposure, neurotrophic, filamentary, bacterial or viral)
  - Postop care after corneal procedures
  - Postop care after pterygium surgery
- Corneal ulcer
- Partial limbal stem-cell deficiency
- Persistent epithelial defects
- Stevens-Johnson Syndrome

BioDOptix® is placed on the surface of the eye and may be held in place by a bandage contact lens (BCL) larger than the tissue. For example, use a 15mm BCL to cover a 12mm BioDOptix®. After 4-7 days, the BCL can be removed.

Q: What CPT code describes application of BioDOptix® on the ocular surface?

A: CPT code 65778 describes this procedure: “Placement of amniotic membrane on the ocular surface; without sutures”. CPT code 92071, “fitting of contact lens for treatment of ocular surface disease” is not separately billable with concurrent 65778; CMS NCCI bundling edits apply.

Q: Does Medicare cover placement of an amniotic tissue allograft?

A: Yes, when medically necessary. Check the payer’s coverage policy for additional limitations.

Q: What is the Medicare allowed amount for 65778?

A: Payment rates vary by site of service. In 2018, the Medicare Physician Fee Schedule allowed amounts are:

Physician (in-office) $1,448
Physician (in-facility) $58

The large site-of-service differential between physician reimbursement in-office and in-facility is due to the supply. Payment for the supply is not made to the physician when the procedure is performed in a facility, and vice versa.

These amounts are adjusted in each locality by local indices. Other payers set their own fee schedules, which may differ considerably from Medicare rates.

Q: Does Medicare pay for the supply of the amniotic tissue separately?

A: No. HCPCS code V2790, Amniotic membrane for surgical reconstruction per procedure, is no longer eligible for discrete Medicare payment in any setting. Reimbursement for the supply is included with payment for the procedure.

Other payers may have different policies regarding amniotic tissue. Check with your payers.

Q: What does Medicare allow as a facility fee for 65778?

A: In 2018, the Medicare facility fee for hospital outpatient department (HOPD) is $808, including payment for the supply. This amount is adjusted in each locality by local indices. Other payers set their own fee schedules, which may differ considerably from Medicare rates.

At present, there is no facility fee for 65778 in an ambulatory surgery center (ASC). This implies that CMS does not expect this service to be performed in an ASC.

Q: What is the postoperative surgical period for 65778?

A: The global surgery period for 65778 is zero days in 2018; in 2015 and earlier it was 10 days.

Q: How am I reimbursed for using amniotic tissue during the postoperative period of another procedure?

A: Reimbursement depends on why and where you administer amniotic tissue.

If amniotic tissue is applied during an exam in a lane or minor treatment room to cope with an unanticipated complication of a prior surgery, your earlier payment for the prior procedure includes postoperative care, including supply of the tissue.

If the use of amniotic tissue is preplanned as part of a staged or anticipated treatment, use 65778-58 on your claim. For example, use of the tissue during the postoperative period of penetrating keratoplasty for high-rejection-risk patients may improve corneal graft survival. The medical record should support this rationale.

If it is applied for a reason unrelated to the prior surgery, use 65778-79. For example, to address a problem in the fellow eye.

Q: How is amniotic tissue reimbursed when used after refractive surgery?

A: Following photorefractive keratectomy (PRK) or related corneal refractive surgery, the use of amniotic tissue is an incidental part of the procedure and not separately reimbursed.

Provided Courtesy of Integra LifeSciences Corporation (609)750-4211

Last updated January 1, 2018

The reader is strongly encouraged to review federal and state laws, regulations, code sets (including ICD-9 and ICD-10), and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. The reader is reminded that this information, including references and hyperlinks, changes over time, and may be incorrect at any time following publication.

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