Reimbursement for Lasering Vitreous Floaters (Ellex)
FREQUENTLY ASKED QUESTIONS:
Reimbursement for Lasering Vitreous Floaters
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Q: What is the medical rationale for treating vitreous floaters?
A: When a floater is significant, limiting vision and compromising the patient’s ability to function, surgical treatment may have merit. That is the exception and not the rule. One published article1 indicates most floaters require no treatment other than patient reassurance.
Q: Is laser treatment of vitreous floaters successful?
A: Maybe. A 2002 article2 described moderate improvements in fewer than 40% of those treated with YAG laser. A recent article described higher success rates.3 There is also a published book4 on the subject which references a formal study completed in March 2005.
Q: Does laser treatment of vitreous floaters require FDA approval of the laser?
A: Probably not. According to Dr. John Karickhoff, “The FDA ruled that our study of laser treatment of vitreous opacities was a non-significant risk device study, and they ruled for the first time that a YAG laser could be used without special approval.” 1
Some Nd:YAG lasers have FDA approval for related indications such as posterior membranectomy.
Q: What factors argue in favor of lasering vitreous floaters?
A: Treating vitreous floaters with laser may be considered in cases where:
- There is moderate to severe disability
- Activities of daily living are seriously hindered
- Symptoms do not resolve over time
- The benefit of treatment outweighs the risk
As with any other surgical procedure, informed consent is critical. It encompasses the risks (such as retinal detachment), benefits, and alternatives to treatment.
Q: Is this procedure reimbursed by third party payers?
A: Usually not. There are few coverage policies on this topic. One, by Aetna, considers this treatment “experimental and investigational … because its effectiveness for these indications has not been established” and therefore not covered.5 Florida Blue Cross/Blue Shield says, “Laser vitre-olysis is considered experimental or investigational … specifically vitreous floaters of the eye…”.6
Q: How is lasering vitreous floaters codified in CPT?
A: There are two CPT codes that apply: 67031 (Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery, one or more stages) and 67299 (Unlisted procedure, posterior segment). Use CPT 67031 when a visually significant opaque floater is severed from its attachment, allowing it to sink to the bottom of the vitreous and out of the line of sight. When severing does not occur, CPT 67031 does not apply. Instead, use CPT 67299 to describe photoablation, destruction, or vaporization of a vitreous floater for complete removal.
Q: What are the payment rates for CPT 67031?
A: The national Medicare Physician Fee Schedule amounts in 2018 for CPT 67031 are: $399.96 for a physician in-office, $365.76 for a physician in a facility. Facility fees are $487.98 for a HOPD, and $254.19 for an ASC.
These amounts are adjusted by local indices, so actual payments will vary. In all cases, other third party payers set their own rates which may vary considerably from Medicare.
Q: What must billers know about unlisted procedure codes (67299)?
A: The use of unlisted codes poses administrative challenges.
- There is no stipulated reimbursement schedule for physicians. Claims are evaluated and an appropriate payment rate is selected on a case-by-case basis.
- There is no published global period.
- Within Medicare, unlisted codes are ineligible for ASC facility fee reimbursement.
- Each claim stands alone; reimbursement for one case does not set precedent for the next.
Q: How frequently is laser vitreolysis performed?
A: Rarely. Within the Medicare program, CPT 67031 was reimbursed 4,916 times in 2016, and CPT 67299 was paid only 408 times. Ophthalmologists who perform this procedure frequently may attract unwanted attention. When a surgeon is challenged during postpayment review of a rarely performed procedure, lucid chart documen-tation is your best defense.
Q: If coverage of laser treatment of vitreous floaters is unlikely or uncertain, how should we proceed?
A: Explain to the patient why laser treatment of vitreous floaters is necessary, and that Medicare or other third party payer will likely deny the claim. Ask the patient to assume financial responsibility for the charge. A financial waiver can take several forms, depending on insurance.
- An Advance Beneficiary Notice of Noncoverage (ABN) is required for services where Part B Medicare coverage is ambiguous or doubtful, and may be useful where a service is never covered. You may collect your fee from the patient at the time of service or wait for a Medicare denial. If both the patient and Medicare pay, promptly refund the patient or show why Medicare paid in error.
- For Part C Medicare (Medicare Advantage), determination of benefits is required to identify beneficiary financial responsibility prior to performing noncovered services; MA Plans may have their own waiver forms.
- For commercial insurance beneficiaries, a Notice of Exclusion from Health Plan Benefits (NEHB) is an alternative to an ABN.
1 Ocular Surgery News. YAG Laser offers safe option for floaters. March 15, 2007. Accessed 01/29/18.
2 Delaney YM, Oyinloye A, Benjamin L. Nd: YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters. Eye. 2002; 16: 21-26. Accessed 01/29/18.
3 Shah CP, Heier JS. YAG Laser Vitreolysis vs Sham YAG Vitreolysis for Symptomatic Vitreous Floaters: A Randomized Clinical Trial. JAMA Ophthalmol 2017;135(9): 918-923. Accessed 01/29/18.
4 Karickhoff J. Laser Treatment of Eye Floaters. Washington Medical Publishing LLC. 2005.
5 Aetna. Policy Number: 0354. YAG Laser in Ophthalmology:Selected Indications. Last reviewed 05/26/2017. Accessed 01/28/18.
6 BC/BS of FL. Medical Coverage Guidelines: Laser Vitreolysis. Rev 05/12/14. Link here. (search on vitreolysis) Accessed 01/29/18.
Provided Courtesy of Ellex, Inc. (800) 824-7444
Last updated February 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.
© 2018 Corcoran Consulting Group. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a retrieval system, without the written permission of the publisher. CPT is a registered trademark of the American Medical Association.
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