Reimbursement for Posterior Segment Laser Photocoagulation (Topcon Medical Systems)
FREQUENTLY ASKED QUESTIONS:
REIMBURSEMENT FOR POSTERIOR SEGMENT LASER PHOTOCOAGULATION
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Q: What are Topcon’s PASCAL lasers?
A: The PASCAL Streamline and Synthesis lasers are sold by Topcon Medical in the US. They are for use in photocoagulation of the posterior segment of the eye (retina and choroid). According to the manufacturer, they are able to achieve satisfactory treatment results with lower overall energy output compared to other laser photocoagulators so that there is “less collateral heat damage to surrounding tissue”. Other unique features are the ability to program treatment patterns in advance and implement them during a laser session. The PASCAL lasers are suitable for use in both office and facility settings.
Q: What are the indications for laser photocoagulation treatment of the posterior segment?
A: There are many. Most commonly, this is done for treatment of diabetic retinopathy (focal or panretinal)1,2 and surrounding retinal holes or tears to prevent retinal detachments.3 Other ophthalmic conditions may benefit from laser photocoagulation, such as macular edema (e.g., branch or central vein occlusions).
Q: Is posterior segment laser photocoagulation covered by Medicare and other payers?
A: Yes, for the proper indications and when supported by the medical record. Few Medicare Administrative Contractors (MACs) have policies for any of these codes.4
Be sure to check for private payer or Medicare Advantage (MA) coverage guidance before initiating treatment and to determine if prior authorization is required.
Q: What CPT codes describe posterior segment laser photocoagulation?
A: While there are many codes that contain the words “photocoagulation”, this FAQ deals only with the following codes:
67105 Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) w/o drainage, 1 or more sessions; photocoagulation
67210 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation
67220 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation 1 or more sessions
67228 Treatment of extensive or progressive retinopathy; (eg diabetic retinopathy), photocoagulation
67229 Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant; (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy.
Q: Are these codes bundled with other services?
A: Yes. According to Medicare’s National Correct Coding Initiative (NCCI), which is revised quarterly, there is an extensive list of bundled codes. In addition, CPT codes 92225 and 92226 (extended ophthalmoscopy, new and subsequent) are bundled with these surgery codes when performed the same day or in the global for the same eye.
Q What does Medicare allow for the surgeon for these laser photocoagulation codes?
A The 2017 national Medicare Physician Fee Schedule allowable amounts are:
These amounts are adjusted by local geographic indices; actual payment amounts will vary.
Q: If we need to repeat laser photocoagulation of the posterior segment, is it billable?
A: Note that most of the codes (except 67105 and 67228) contain the descriptor “one or more sessions”. “One or more sessions” means that any treatment with the same code for the same eye within the 90 day global period is not payable for the surgeon. The CPT manual states, “Codes 67208, 67210 … 67220, 67229 … include treatment at one or more sessions that may occur at different encounters. These codes should be reported once during a defined treatment period.”
In 2016, 67228 was changed to a global period of 10 days; in 2017, the same change was made to 67105. Consequently, these codes are reclassified as minor procedures, with possible restrictions on billing the same-day eye exam. See our FAQ on Modifier 25 for more information.
Remember that global periods do not exist for facilities – each laser treatment is billed.
Q: What does Medicare allow for the facility fee for these procedures?
A: All of the codes in this FAQ are classified into APC 5481. However, due to differences in payment methodology for hospitals and ambulatory surgery centers, the fee schedule amounts vary. In 2017, the national Medicare fee schedule amounts are:
These amounts are modified by local indices, so actual payments will vary.
1 National Eye Institute. Press Release. Laser Treatment Effective for Diabetic Retinopathy. April 1, 1976. Link here.
2 National Eye Institute. Clinical Alert to Ophthalmologists. Early Treatment Diabetic Retinopathy Study (ETDRS). October 30, 1989. Link here.
3 American Academy of Ophthalmology. Preferred Practice Patterns (listing shows multiple document access). Link here.
4 National Government Services, Inc. LCD L33628. Panretinal (Scatter) Photocoagulation. Rev eff. 10/01/2016. Link here.
Provided Courtesy of Topcon Medical Systems (800) 223-1130
Last updated July 10, 2018
The reimbursement information is provided by Corcoran Consulting Group based on publicly available information from CMS, the AMA, and other sources. The reader is strongly encouraged to review federal and state laws, regulations, code sets, and official instructions promulgated by Medicare and other payers. This document is not an official source nor is it a complete guide on reimbursement. Although we believe this information is accurate at the time of publication, 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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