Reimbursement for Laser Photocoagulation (Nidek)
FREQUENTLY ASKED QUESTIONS:
Reimbursement for Laser Photocoagulation (Nidek)
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Q: What are Nidek’s GYC-500 and GYC-500 Vixi lasers?
A: The GYC-500 and GYC-500 Vixi lasers are sold by Nidek in the US. They are used in photocoagulation of the anterior (iris, angle) and posterior (retina, choroid) segments of the eye. According to Nidek, both lasers are green-wave-length, compact, solid-state units with the capability to be table (slit-lamp) or indirect-ophthalmoscopy headset mounted; the Vixi unit can also perform a variety of pre-programmed scan patterns. Both models are suitable for use in the office or facility.
Q: What are the indications for laser photocoagulation treatment of the eye?
A: There are many. Most commonly, posterior segment treatment is done for 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).
Anterior segment laser treatments are typically done for iris and open-angle and narrow- angle glaucoma treatments.4
Q: Are these laser procedures covered by Medicare and other payers?
A: Yes, for the proper indications and when supported by the medical record, although few Medicare Administrative Contractors (MACs) have policies for any of these codes.5,6 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 laser photocoagulation of the eye?
A: While there are many codes that contain the words “photocoagulation”, this FAQ addresses only the following codes:
Q: Are these codes bundled with other services?
A: Yes. According to Medicare’s National Correct Coding Initiative (NCCI), there is an extensive list of bundled surgical codes. Also, extended ophthalmoscopy (92225, 92226) is bundled with the posterior segment codes when performed the same day or in the global surgery period for the same eye.
Q: What does Medicare allow for these procedures?
A: The 2018 national Medicare Physician Fee Schedule allowable amounts are:
For the facility payments, all of these codes are classified into APC 5481. However, due to differences in payment methodology for hospitals and ambulatory surgery centers, the ASC fee schedule amounts vary. The 2018 national Medicare allowed amounts are:
These amounts are modified by local indices, so actual payments will vary.
Q: If we need to repeat laser photocoagulation, is it billable?
A: Sometimes. Note that most of the codes (except 65855, 66761, 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 assigned a global period of 10 days; in 2017, the same change was made to 67105. Consequently, these codes were reclassified as minor procedures, with possible restrictions on billing a same-day eye exam. 65855 and 66761 are already classified as minor procedures. See our FAQ on Modifier 25 for more information.
Remember that global periods do not exist for facilities – each laser treatment is billed.
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 Juzych MS, Chopra V, et al. Comparison of long-term outcomes of selective laser trabeculoplasty versus argon laser trabeculoplasty in open-angle glaucoma. Ophthalmology. 2004 Oct;111(10):1853-9. Link to PubMed abstract here.
5 National Government Services, Inc. LCD L33628. Panretinal (Scatter) Photocoagulation. Rev eff. 10/01/2016. Link here
6 First Coast Service Options, Inc. LCD L33917. Laser Trabeculoplasty. Rev eff. 10/01/2016. Link here.
Provided Courtesy of Nidek (800) 223-9044
Last updated May 10, 2018
The reader is strongly encouraged to review federal and state laws, regulations, code sets (including 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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