Reimbursement for Omidria
Omidria (phenylephrine and ketorolac injection) 1% / 0.3% is used during cataract and lens replacement surgery (i.e., refractive lens exchange or IOL exchange) to maintain pupil size by preventing intraoperative miosis (pupil constriction) and to reduce postoperative pain. Each 4-ml single-patient-use vial of Omidria is diluted in a standard 500-ml container of irrigation solution for use during the procedure; it requires no change in the surgeon’s operating routine. The Food and Drug Administration (FDA) approved Omidria on May 30, 2014.
This FAQ addresses the following:
- What is Omidria®?
- Is Omidria indicated for intra-ocular surgery other than lens extraction or lens exchange?
- What CPT code(s) describes cataract surgery with IOL placement?
- What CPT code describes refractive lens exchange?
- Do Medicare and other third party payers cover Omidria?
- Is there separate payment to the facility for Omidria?
- What is the Medicare ASC reimbursement for Omidria?
- What HCPCS code is used on claims for reimbursement for Omidria?
- Is Omidria subject to the Medicare 20% copayment rule?
- Does the use of Omidria affect the surgeon’s reimbursement?
- Are there purchasing concerns for facilities related to Omidria?
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